You are on page 1of 148

MEMBER GUIDE 2012

TABLE OF CONTENTS

1. 2. 3.

KEYHEALTH MEDICAL SCHEME INTRODUCTION GLOSSARY AND ABBREVIATIONS BENEFIT STRUCTURE AND CONTRIBUTIONS 3.1 3.2 3.3 3.4 3.5 PLATINUM OPTION GOLD OPTION SILVER OPTION EQUILIBRIUM OPTION ESSENCE OPTION

7 11 17 19 27 35 41 47 53 54 57 59 60 61 63 65

4.

MEMBERSHIP 4.1 4.2 4.3 4.4 4.5 4.6 MEMBERSHIP APPLICATION UNDERWRITING MEMBERSHIP CHANGES RETIREMENT / DEATH OF PRINCIPAL MEMBER CONTRIBUTIONS TERMINATION OF MEMBERSHIP

5.

PRESCRIBED MINIMUM BENEFITS (PMBs)

6.

MEDICATION 6.1 6.2 6.3 6.4 PRESCRIBED ACUTE MEDICATION MAXIMUM MEDICAL SCHEME PRICE (MMAP) OVER-THE-COUNTER MEDICATION REGISTRATION FOR CHRONIC CONDITIONS AND PRESCRIBED CHRONIC MEDICATION 6.5 THE CONDITION MEDICINE LIST (CML) 6.6 REFERENCE PRICE 6.7 OTHER CHRONIC CONDITIONS (PLATINUM OPTION) 6.8 BIOLOGICAL MEDICINE 6.9 DSP PHARMACIES 6.10 CHRONIC MEDICATION ON TRAVELLING ABROAD

71 72 73 73 74 74 75 77 78 80 81 83 84 85 87 87 87 88 91 92 92 94 97 101 105

7.

HOSPITALISATION AND MANAGED HEALTHCARE 7.1 7.2 7.3 7.4 7.5 7.6 AUTHORISATION OF HOSPITAL ADMISSIONS DISEASE / CASE MANAGEMENT MATERNITY PROGRAMME MEDICAL APPLIANCES PROSTHETICS OUTPATIENTS

8.

DENTAL BENEFITS 8.1 DENIS CONTACT DETAILS 8.2 GENERAL DENTAL INFORMATION 8.3 HOSPITALISATION BENEFITS

9.

OPTICAL BENEFITS

10. EMERGENCY TRANSPORT 11. CO-PAYMENTS

12. CLAIMS 12.1 CLAIMS PROCEDURES 12.2 MOTOR VEHICLE ACCIDENT (MVA) 12.3 INJURY ON DUTY (IOD) 12.4 CLAIMS STATEMENT 12.5 TRAVELLING ABROAD 13. MEDICAL SAVINGS ACCOUNT (MSA) 14. LIST OF EXCLUSIONS 15. HEALTH BOOSTER 16. FRAUD / UNETHICAL CONDUCT 17. ELECTRONIC COMMUNICATION 17.1 VIA THE INTERNET 17.2 VIA E-MAIL (WEBMAIL) 17.3 VIA SMS 18. IMPORTANT CONTACT INFORMATION

111 112 115 115 115 116 119 123 131 135 139 140 142 142 145

01 | KEYHEALTH MEDICAL SCHEME

08

KEYHEALTH MEMBER GUIDE 2012

01| KEYHEALTH MEDICAL SCHEME


1.1 KEYHEALTH
KeyHealth (referred to as the Scheme) has a formidable footprint in the industry (more than 85 000 lives) and provides a diverse range of products designed to cater for many different medical needs, real value for money for discerning individuals and families that know what they need. Through various amalgamations, including Pretmed, Global Health and Munimed, the Scheme boasts a proud lineage dating back to the beginning of the 20th Century. KeyHealth therefore exemplifies longevity, dependability and stability. KeyHealth is an open medical scheme; meaning any member of the public can join. However, the Scheme is also one of only five accredited schemes selected to operate within Local Government in South Africa.

1.2 SCHEME RULES


It is imperative for members to study and have a clear understanding of the Scheme Rules in order to avoid misconceptions and prevent resultant mistakes. Please note: This Member Guide is only a summary of the latest Scheme Rules. A copy of the official rules is available on request or on the website at www.keyhealthmedical.co.za. In the event of a dispute, the latest official Scheme Rules, as registered with the Council for Medical Schemes, will apply.

1.3 LIMITATION OF EXPENDITURE


The careful use of medical services will assist in containing members Scheme expenditure and limit future increases in membership fees to a minimum.

KEYHEALTH MEMBER GUIDE 2012

09

1.4 EXCHANGE OF BENEFITS PROHIBITED


Legislation prohibits the exchange of benefits between service categories, e.g. chronic medicine benefits may not be used for the payment of acute medicine claims.

1.5 THE MEMBERS RESPONSIBILITIES


Always comply with the prescribed treatment procedures. Enquire about the related costs of treatment when consulting service providers. Keep a record of all relevant medical documentation. Stay abreast of services offered by local health facilities. Ensure that the information reflected on statements is correct, and keep statements for future reference. Follow up on claims that have not been paid. [A claim becomes stale four (4) months from date of service, and payment will then be the responsibility of the member.] Read, take notice of and, if required, act upon all communication received from the Scheme. Manage benefits new benefits received at the beginning of every benefit year are the members healthcare budget for that year; use it wisely and report abuse to the Scheme without delay.

02 | GLOSSARY, ABBREVIATIONS & EXPLANATIONS

012

KEYHEALTH MEMBER GUIDE 2012

02| GLOSSARY, ABBREVIATIONS & EXPLANATIONS


PM AD CD MSA pbpa pbp2a pfpa pfp2a 2pfpa = Principal Member = Adult Dependant = Child Dependant = Medical Savings Account = per beneficiary per annum (per year) = per beneficiary biennially (every second year) = per family per annum (per year) = per family biennially (every second year) = two (2) (times) per family per annum (per year)

Agreed tariff: A tariff as agreed upon between the Scheme and certain service providers. Angiogram: An angiogram is an X-ray examination where a special dye and camera (fluoroscopy) are employed to take pictures of the blood flow in arteries. Beneficiary: A Principal Member of the Scheme or a person registered as a Dependant of a Principal Member. Case management: The application of Rules, clinical protocols and medical procedures for the treatment of specific conditions. Chronic Disease List (CDL): A list of chronic illness conditions that are covered by the Scheme in terms of applicable legislation. Chronic medication: Prescribed medication continuously used for more than three (3) months for chronic conditions contained in the Schemes PMB CDL (Category A, 26 conditions all options) and/or the Other Conditions (Category B, 29 conditions Platinum option only).

KEYHEALTH MEMBER GUIDE 2012

013

Conservative dentistry: Basic dental services, such as fillings, extractions and oral hygiene. Co-payment: The portion of the amount due that a Member must pay directly to the service provider involved and in accordance with the latest Scheme Rules. CT and MRI scans: Specialised, high definition external scanning methods for internal bodily examinations. Day-to-day benefit: On the Platinum, Gold, Silver and Equilibrium options - an annual, combined, non-transferable, out-of-hospital limit which may be utilised (with due allowance for certain limitations) by any of the registered Beneficiaries in respect of products and services as stated in the latest version of the different benefit structures. Dental management: A cost and quality Dental Management Programme provided and managed by DENIS (Dental Information Systems). Designated Service Provider (DSP): A healthcare provider or group of providers selected by the Scheme as the preferred provider(s) to supply its Members with diagnosis, treatment and health products at specific negotiated tariffs. Emergency: An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death. Generic medicine: Medicine with the same active ingredients and medicinal effect as the original brand name counterpart, but usually lower in price.

014

KEYHEALTH MEMBER GUIDE 2012

Health Booster: An additional benefit for preventive care available to Beneficiaries of the Scheme at no extra cost. MMAP: Maximum Medical Aid Price - MediKredits MMAP is a guideline to determine the maximum price that medical schemes will reimburse for specific pharmaceutical products. Medical Scheme Tariff (MST): The maximum tariff the Scheme is willing to pay for services rendered by healthcare service providers. NAPPI code: National Pharmaceutical Product Interface codification used for unique medication identification. Oncology: The treatment of cancer. Optical management: A cost and quality Optical Management Programme provided by Opticlear. PET scan: A Positron Emission Tomography scan - an imaging study using a very small dose of a radioactive tracer that helps to distinguish cancer from benign tissue to assist in assessing the response of cancer to therapy. Physical trauma: A severe bodily injury due to violence or an accident, e.g. a gunshot, stabbing, a fracture or a motor vehicle accident, causing serious and life-threatening physical injury, potentially resulting in secondary complications such as shock, respiratory failure or death. This includes penetrating, perforating and blunt force trauma. Platinum option: The day-to-day benefits on the Platinum option comprise the following: - Routine portion - Self-funding gap - Threshold

KEYHEALTH MEMBER GUIDE 2012

015

When the routine portion has been depleted, the Member is responsible for the payment of day-to-day expenses, and submits proof of cash payments (copy of account and receipt) to the Scheme, as these claims accumulate to the total of the self-funding gap. The self-funding gap will accumulate according to MST rates. Threshold: Once the self-funding gap has been bridged, the Member will have access to further benefits. (See Chapter 3: Benefit Structure and Contributions, for details.) Over-the-counter medication is included in the self-funding gap and threshold with a sub-limit. (See Chapter 3: Benefit Structure and Contributions, for details.) Special Dependant: The immediate family of a Principal Member and/or his Spouse/Partner (i.e. parents, in-laws, grand children, brothers and/or sisters). In the case of grandchildren, the relevant legal documentation is a membership requirement.

03 | BENEFIT STRUCTURE & CONTRIBUTIONS

3.1| PLATINUM OPTION

020

KEYHEALTH MEMBER GUIDE 2012

3.1| PLATINUM OPTION


IN-HOSPITAL TOTAL ANNUAL BENEFIT
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT Private Hospitals State hospitals 100% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R385

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory.

R36 000

SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY

100% R30 000 R10 500 100% 100%

Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined in- and out-of-hospital. Sublimit of R15 000 pfpa on out-of-hospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Unlimited. Pre-authorisation compulsory and subject to case management.

100% 100% 100%

Unlimited. Pre-authorisation compulsory and subject to case management. Unlimited. Pre-authorisation compulsory and subject to case management. Pre-authorisation compulsory for specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.) R15 000 Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. Unlimited number of scans. Limited to R11 000 per scan.

MRI and CT scans X-rays PET scans

KEYHEALTH MEMBER GUIDE 2012

021

IN-HOSPITAL TOTAL ANNUAL BENEFIT


PATHOLOGY PROSTHETICS (Internal and External)

MST ()
100% 100% 80%

BENEFIT
R55 000

EXPLANATORY NOTES / BENEFIT SUMMARY


Unlimited Pfpa, combined benefit. Pre-authorisation compulsory and subject to case management, protocols and pricing. 20% co-payment when limit is exceeded.

OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy.

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY

Limited to: Principal Member: R6 550 p.a. Adult Dependant: R6 350 p.a. Child Dependant: R1 550 p.a.

90% 90% Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES 100% R1 800 R125 100% R3 200

Frames Lenses Eye test Contact lenses Refractive surgery PHYSIOTHERAPY PATHOLOGY

R950

100% 80%

R1 500 R6 400 R8 500 R8 500

Self-funding gap : (MST) PM: R2 290 AD: R2 040 CD: R750 Threshold: co-payment on all services in threshold zone. Prescribed medicine: sublimit in threshold zone of PM: R5 400 AD: R2 450 CD: R1 200 Pfpa sublimit. Subject to day-to-day and threshold. Pbpa; one (1) pair per year. Subject to overthe-counter medicine sublimit. Pbp2a total optical benefit. Subject to day-to-day benefit, threshold and Optical Management. Benefit confirmation compulsory. Per frame, one (1) frame pbp2a. Subject to overall optical benefit. One (1) pair pbp2a. Subject to overall optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Pbp2a. Pre-authorisation compulsory. Pfpa sublimit. Subject to day-to-day benefit and threshold. Pfpa sublimit. Subject to day-to-day benefit and threshold. (Co-payment payable directly to the service provider involved.)

022

KEYHEALTH MEMBER GUIDE 2012

OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

Consultations X-rays: Intra-oral X-rays: Extra-oral

100% 100% 100%

Two (2) check-ups pbpa. One (1) pbp3a. (Additional benefit may be granted where specialised dental treatment planning / follow-up is required.) Two (2) scale and polish treatments pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols. One (1) set (an upper and a lower jaw) pbp4a. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. Two (2) frames (an upper and a lower jaw) pbp5a. DENIS pre-authorisation compulsory. A treatment plan and X-rays may be requested. One (1) per tooth pbp5a. Pbpa limitation on cost of implant components. DENIS pre-authorisation compulsory. DENIS pre-authorisation compulsory. Cases will be clinically assessed using orthodontic indices. Where function is impaired. Not for cosmetic reasons; laboratory costs also excluded. Only one (1) Beneficiary per family may commence treatment per calendar year. Limited to Beneficiaries younger than 18 years. DENIS pre-authorisation compulsory. Limited to conservative, non-surgical therapy (root planing) only and will be applied to Beneficiaries registered on the Perio Programme.

Oral hygiene Fillings Root canal treatment and tooth extractions Plastic dentures Specialised dentistry Partial metal frame dentures Crowns and bridges

100% 100% 100% 100%

80% 80%

Implants Orthodontics

80% 80%

R2 700

Periodontics

80%

KEYHEALTH MEMBER GUIDE 2012

023

OUT-OF-HOSPITAL BENEFIT
[DENTISTRY Continued] Maxillo-Facial and Oral surgery Surgery in dental chair

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY

Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% DENIS pre-authorisation not required. Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical intervention/treatment. Claims for oral pathology procedures (cysts, biopsies and tumour removals) only covered if supported by a laboratory report confirming diagnosis. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% R1 000 co-payment per hospital admission. Extensive dental treatment for very young Child Dependants. Removal of impacted wisdom teeth. DENIS pre-authorisation compulsory. DENIS pre-authorisation not required.

Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia)

100%

Laughing gas in dental 100% rooms DENIS pre-authorisation compulsory. IV conscious sedation in 100% Limited to extensive dental treatment. dental rooms PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED

024

KEYHEALTH MEMBER GUIDE 2012

CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIES


CHRONIC MEDICATION Category A (CDL) (Refer to chapter 6: Medication) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (10% co-payment applicable when using a non-DSP pharmacy.) R11 500 Pbpa, with a maximum of R23 500 pfpa. 10% co-payment applicable when using a non-DSP pharmacy. 10% co-payment not applicable to PMB conditions. (Co-payment payable directly to the service provider involved.) Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. R7 000 Pfpa; combined in- and out-of-hospital benefit.

Category B (other) (Refer to chapter 6: Medication)

90%

HIV/AIDS

100%

R35 000

State hospitals AMBULANCE SERVICES

100%

MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). HEARING AIDS Hearing aids Maintenance (batteries included) ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)

100%

100% R11 500 R800 100%

No authorisation required. Pfp4a. Pbpa. Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).

MONTHLY CONTRIBUTION
Monthly contribution Principal Member R4 061 Adult Dependant R2 846 Child Dependant R855

KEYHEALTH MEMBER GUIDE 2012

025

NOTES:

3.2| GOLD OPTION

028

KEYHEALTH MEMBER GUIDE 2012

3.2| GOLD OPTION


IN-HOSPITAL TOTAL ANNUAL BENEFIT
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT Private Hospitals State hospitals 100% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R335

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory.

R24 500

SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS

100% R24 500

Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined benefit; in- and out-ofhospital. Sublimit of R10 000 pfpa on out-ofhospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only. Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management. Pre-authorisation compulsory for specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (MSA / day-to-day benefits will then apply.) Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. Unlimited number of scans. Limited to R11 000 per scan.

R8 000 100% 100%

100%

ONCOLOGY RADIOLOGY

100% 100%

R220 000

MRI and CT scans X-rays PET scans

R10 000

KEYHEALTH MEMBER GUIDE 2012

029

IN-HOSPITAL TOTAL ANNUAL BENEFIT


PATHOLOGY PROSTHETICS (Internal and External)

MST ()
100% 100%

BENEFIT
R22 500

EXPLANATORY NOTES / BENEFIT SUMMARY


Unlimited Pfpa, combined benefit. Pre-authorisation compulsory and subject to case management, protocols and pricing.

OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy. Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY

Annual Medical Savings Account (MSA): Principal Member: R3 096 p.a. Adult Dependant: R2 088 p.a. Child Dependant: R600 p.a. Additional benefits limited to: Principal Member: R2 540 p.a. Adult Dependant: R1 890 p.a. Child Dependant: R600 p.a.

100%

R1 200 R105

100%

R1 900

Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY 60%

R600

R900

Pfpa sublimit. Subject to MSA / day-to-day benefit. Pbpa; one (1) pair per year. Subject to overthe-counter medicine sublimit. Pbp2a total optical benefit. Subject to MSA / day-to-day benefit and Optical Management. Benefit confirmation compulsory. Per frame, one (1) frame pbp2a. Subject to overall optical benefit. One (1) pair pbp2a. Subject to overall optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Subject to overall optical benefit. Pre-authorisation compulsory - subject to overall optical benefit. Subject to MSA / day-to-day benefit. (Copayment payable directly to the service provider involved.)

030

KEYHEALTH MEMBER GUIDE 2012

OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

Consultations X-rays: Intra-oral X-rays: Extra-oral Oral hygiene Fillings

100% 100% 100% 100% 100%

Two (2) check-ups pbpa. One (1) pbp3a. (Additional benefit may be granted where specialised dental treatment planning / follow-up is required.) Two (2) scale and polish treatments pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols.

Root canal treatment and tooth extractions Plastic dentures Specialised dentistry Partial metal frame dentures Crowns and bridges

100% 100% One (1) set (an upper and a lower jaw) pbp4a. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. One (1) partial metal frame (an upper or a lower jaw) pbp5a. DENIS pre-authorisation compulsory. A treatment plan and X-rays may be requested. One (1) per tooth pbp5a. No benefit. Subject to MSA. DENIS pre-authorisation compulsory. Cases will be clinically assessed using orthodontic indices. Where function is impaired. Not for cosmetic reasons; laboratory costs also excluded. Only one (1) Beneficiary per family may commence treatment per calendar year. Limited to Beneficiaries younger than 18 years. DENIS pre-authorisation compulsory. Limited to conservative, non-surgical therapy (root planing) only and will be applied to Beneficiaries registered on the Perio Programme.

80% 80%

Implants Orthodontics

80%

Periodontics

80%

KEYHEALTH MEMBER GUIDE 2012

031

OUT-OF-HOSPITAL BENEFIT
[DENTISTRY Continued] Maxillo-Facial and Oral surgery Surgery in dental chair

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY

100%

Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia)

100%

Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. DENIS pre-authorisation not required. Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical intervention/treatment. Claims for oral pathology procedures (cysts, biopsies and tumour removals) only covered if supported by a laboratory report confirming diagnosis. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

100%

R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Extensive dental treatment for very young Child Dependants. Removal of impacted wisdom teeth.

DENIS pre-authorisation not required. Laughing gas in dental 100% rooms DENIS pre-authorisation compulsory. IV conscious sedation in 100% Limited to extensive dental treatment. dental rooms PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED

032

KEYHEALTH MEMBER GUIDE 2012

CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIES


CHRONIC MEDICATION Category A (CDL) (Refer to chapter 6: Medication) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (15% co-payment applicable when using a non-DSP pharmacy.) No benefit. Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit.

Category B (other) HIV/AIDS

100%

R29 000

State hospitals AMBULANCE SERVICES

100%

MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). HEARING AIDS Hearing aids Maintenance (batteries included) ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)

100% R5 500

100% R5 800 R600 100%

No authorisation required. Pfp4a. Pbpa. Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).

MONTHLY CONTRIBUTION
Principal Member Monthly contribution R2 326 Monthly savings R258 Total monthly contribution R2 584 Adult Dependant R1 571 R174 R1 745 Child Dependant R455 R50 R505

KEYHEALTH MEMBER GUIDE 2012

033

NOTES:

3.3| SILVER OPTION

036

KEYHEALTH MEMBER GUIDE 2012

3.3| SILVER OPTION


IN-HOSPITAL TOTAL ANNUAL BENEFIT
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory. Co-payment per surgical procedure (no out-of-hospital co-payments): Varicose vein surgery - R1 000 Umbilical hernia repair - R1 000 Facet joint injections - R1 000 Functional nasal surgery - R2 000 Hysterectomy - R2 500 Rhizotomy - R2 500 Reflux surgery - R5 000 Back surgery (including spinal fusion) - R5 000 Joint replacement - R5 000 Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined benefit; in- and out-ofhospital. Sublimit of R5 000 pfpa on out-ofhospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only.

Private Hospitals State hospitals 100% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R165

R12 000

SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound Care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS

100% R18 000 R5 800 100% 100%

100%

ONCOLOGY

100%

R106 000

Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management.

KEYHEALTH MEMBER GUIDE 2012

037

IN-HOSPITAL TOTAL ANNUAL BENEFIT


RADIOLOGY

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory for specialised radiology, including MRI and CT scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.) Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. No benefit. Unlimited Pre-authorisation compulsory and subject to case management, protocols and pricing. PMB conditions / trauma only.

MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)

R10 000

100% 100%

OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy. Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY

Limited to: Principal Member: R4 660 p.a. Adult Dependant: R3 390 p.a. Child Dependant: R940 p.a. 2pfpa - additional General Practitioner consultations after depletion of available dayto-day benefit.

100%

R980 R85

Pfpa sublimit. Subject to day-to-day benefit. Pbpa; one (1) pair per year. Subject to overthe-counter medicine sublimit. Pbp2a total optical benefit. Subject to dayto-day benefit and Optical Management. Benefit confirmation compulsory. Per frame, one (1) frame pbp2a. Subject to overall optical benefit. One (1) pair single vision lenses pbp2a. Subject to overall optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Subject to overall optical benefit. No benefit. Subject to day-to-day benefit. (Co-payment payable directly to the service provider involved.)

100%

R950 R320

R420 60%

038

KEYHEALTH MEMBER GUIDE 2012

OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

Consultations X-rays: Intra-oral X-rays: Extra-oral Oral hygiene Fillings Root canal treatment and tooth extractions Plastic dentures Specialised dentistry Maxillo-Facial and Oral surgery Surgery in dental chair

100% 100% 100% 100% 100% 100% 100%

Two (2) check-ups pbpa. One (1) pbp3a. Two (2) scale and polish treatments pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols.

One (1) set (an upper and a lower jaw) pbp4a. No benefit Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

100%

DENIS pre-authorisation not required. Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical intervention / treatment. Claims for oral pathology procedures (cysts, biopsies and tumour removals) only covered if supported by a laboratory report confirming diagnosis. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia) Laughing gas in dental rooms

100%

100%

R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.

100%

IV conscious sedation in 100% DENIS pre-authorisation compulsory. dental rooms Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED

KEYHEALTH MEMBER GUIDE 2012

039

CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIES


CHRONIC MEDICATION Category A (CDL) (Refer to chapter 6: Medication) Category B (other) HIV/AIDS 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (30% co-payment applicable when not using a DSP pharmacy.) No benefit. Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit. Hearing aids subject to case management and protocols.

100%

R23 500

State hospitals AMBULANCE SERVICES

100%

MEDICAL APPLIANCES Wheelchairs, orthopedic appliances, hearing aids and incontinence equipment (including contraceptive devices and maintenance of hearing aids). ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)

100% R4 500

100%

Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).

MONTHLY CONTRIBUTION
Monthly contribution Principal Member R1 937 Adult Dependant R1 041 Child Dependant R402

3.4| EQUILIBRIUM OPTION

042

KEYHEALTH MEMBER GUIDE 2012

3.4| EQUILIBRIUM OPTION


IN-HOSPITAL TOTAL ANNUAL BENEFIT
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory. Co-payment per surgical procedure (no out-of-hospital co-payments): Varicose vein surgery - R1 000 Umbilical hernia repair - R1 000 Facet joint injections - R1 000 Functional nasal surgery - R2 000 Hysterectomy - R2 500 Rhizotomy - R2 500 Reflux surgery - R5 000 Back surgery (including spinal fusion) - R5 000 Joint replacement - R5 000 Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined benefit; in- and out-ofhospital. Sublimit of R5 000 pfpa on out-ofhospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. PMB conditions only.

Private Hospitals State hospitals 150% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R335

R12 000

SUB-ACUTE FACILITIES & WOUND CARE Wound care, hospice, private nursing, rehabilitation and stepdown facilities. BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS

100%

100% 100%

Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only.

100%

ONCOLOGY

100%

R95 000

Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management.

KEYHEALTH MEMBER GUIDE 2012

043

IN-HOSPITAL TOTAL ANNUAL BENEFIT


RADIOLOGY

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory for specialised radiology, including MRI and CT scans. Hospitalisation not covered if radiology is for investigative purposes only. (MSA / day-to-day benefits will then apply.) Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. No benefit. Unlimited Pre-authorisation compulsory and subject to case management, protocols and pricing. PMB conditions / trauma only.

MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)

R10 000

100% 100%

OUT-OF-HOSPITAL BENEFIT
DAY-TO-DAY BENEFIT General Practitioner and Specialist consultations. Radiology. Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy and occupational therapy. Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY

Annual Medical Savings Account (MSA): Principal Member: R1 116 p.a. Adult Dependant: R672 p.a. Child Dependant: R336 p.a. Additional benefits limited to: Principal Member: R1 590 p.a. Adult Dependant: R890 p.a. Child Dependant: R480 p.a. R75 Pbpa; one (1) pair per year. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. Subject to MSA / day-to-day benefit. No benefit. Subject to MSA. Subject to MSA / day-to-day benefit.

100%

100%

044

KEYHEALTH MEMBER GUIDE 2012

OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

Consultations

100%

One (1) check-up pbpa. Three (3) specific (emergency) consultations pbpa. Four (4) peri-apical radiographs pbpa. One (1) pbp3a. One (1) scale and polish treatment pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols. No benefit. Subject to MSA. No benefit. Subject to MSA. No benefit. Subject to MSA. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

X-rays: Intra-oral X-rays: Extra-oral Oral hygiene Fillings

100% 100% 100% 100%

Tooth extractions Root canal treatment Plastic and metal frame dentures Specialised dentistry Maxillo-Facial and Oral surgery Surgery in dental chair Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia) Laughing gas in dental rooms

100%

100% 100%

DENIS pre-authorisation not required. Wisdom teeth removal only. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

100%

R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.

100%

IV conscious sedation in 100% DENIS pre-authorisation compulsory. dental rooms Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED

KEYHEALTH MEMBER GUIDE 2012

045

CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIES


CHRONIC MEDICATION Category A (CDL) (Refer to chapter 6: Medication) Category B (other) HIV/AIDS 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (30% co-payment applicable when not using a DSP pharmacy.) No benefit. Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit.

100%

R21 000

State hospitals AMBULANCE SERVICES

100%

MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). Hearing aids and maintenance ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)

100% R4 500

No benefit. Subject to MSA. 100% Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).

MONTHLY CONTRIBUTION
Monthly contribution Monthly savings Total monthly contribution Principal Member R1 070 R 93 R1 163 Adult Dependant R645 R56 R701 Child Dependant R327 R28 R355

3.5| ESSENCE OPTION

048

KEYHEALTH MEMBER GUIDE 2012

3.5| ESSENCE OPTION


IN-HOSPITAL TOTAL ANNUAL BENEFIT
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory. Co-payment per surgical procedure (no out-of-hospital co-payments): Varicose vein surgery - R1 000 Umbilical hernia repair - R1 000 Facet joint injections - R1 000 Functional nasal surgery - R2 000 Hysterectomy - R2 500 Rhizotomy - R2 500 Reflux surgery - R5 000 Back surgery (including spinal fusion) - R5 000 Joint replacement - R5 000 Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa Pre-authorisation compulsory and subject to case management. PMB conditions only.

Private Hospitals State hospitals 100% Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% R275

R12 000 SUB-ACUTE FACILITIES & WOUND CARE Wound care, hospice, private nursing, rehabilitation and stepdown facilities. BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS 100%

100% 100%

Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only.

100%

ONCOLOGY

100%

R95 000

Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management.

KEYHEALTH MEMBER GUIDE 2012

049

IN-HOSPITAL TOTAL ANNUAL BENEFIT


RADIOLOGY

MST ()
100%

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Pre-authorisation compulsory for specialised radiology, including MRI and CT scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.) Pfpa. R1 000 co-payment per scan (in- or outof-hospital), excluding confirmed PMBs. Unlimited. No benefit. Unlimited Pre-authorisation compulsory and subject to case management, protocols and pricing. PMB conditions / trauma only.

MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)

R 10 000

100% 100%

OUT-OF-HOSPITAL BENEFIT
Over-the-counter medication Over-the-counter reading glasses PATHOLOGY OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery

MST ()
100%

BENEFIT
R445 R75

EXPLANATORY NOTES / BENEFIT SUMMARY


Pbpa Pbpa; one (1) pair per year. Subject to overthe-counter medication benefit. No benefit, except for PMB conditions. No benefit. No benefit. No benefit. No benefit. No benefit.

050

KEYHEALTH MEMBER GUIDE 2012

OUT-OF-HOSPITAL BENEFIT
DENTISTRY Conservative dentistry

MST ()

BENEFIT

EXPLANATORY NOTES / BENEFIT SUMMARY


Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

Consultations

100%

One (1) check-up pbpa. Three (3) specific (emergency) consultations pbpa. Four (4) peri-apical radiographs pbpa. One (1) pbp3a. One (1) scale and polish treatment pbpa. A treatment plan and X-rays may be required for multiple fillings. Re-treatment of a tooth subject to clinical protocols. No benefit. No benefit. No benefit. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

X-rays: Intra-oral X-rays: Extra-oral Oral hygiene Fillings

100% 100% 100% 100%

Tooth extractions Root canal treatment Plastic and metal frame dentures Specialised dentistry Maxillo-Facial and Oral surgery Surgery in dental chair Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia) Laughing gas in dental rooms

100%

100% 100%

DENIS pre-authorisation not required. Wisdom teeth removal only. DENIS pre-authorisation compulsory. (See Hospitalisation below.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.

100%

R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.

100%

IV conscious sedation in 100% DENIS pre-authorisation compulsory. dental rooms Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED

KEYHEALTH MEMBER GUIDE 2012

051

CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIES


CHRONIC MEDICATION Category A (CDL) (Refer to chapter 6: Medication) Category B (other) HIV/AIDS State hospitals AMBULANCE SERVICES 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (30% co-payment applicable when not using a DSP pharmacy.) No benefit. Pfpa. Subject to registartion on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit.

100%

R21 000

100%

MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). Hearing aids and maintenance ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)

100% R4 500

No benefit. 100% Pre-authorisation compulsory. No co-payment on out-of-hospital scopes. R1 500 co-payment per scope (in-hospital). R2 000 co-payment per scope (in-hospital). R2 500 co-payment per scope (in-hospital).

MONTHLY CONTRIBUTION
Monthly contribution Principal Member R899 Adult Dependant R543 Child Dependant R275

04 | MEMBERSHIP

054

KEYHEALTH MEMBER GUIDE 2012

4.1| MEMBERSHIP APPLICATION


KeyHealth is an open medical scheme, and membership is available to private individuals and employer groups, including Local Government employees. Legislation prohibits a person from belonging to more than one medical scheme at a time. Supplementary documentation required when applying for membership (Principal Member and Adult / Child Dependant):

WHO
Principal Member Biological baby

WHAT
Copy of ID. Membership certificate from previous medical scheme (if applicable). Copy of ID. Copy of marriage certificate / proof of marriage. Membership certificate from previous medical scheme (if applicable). Copy of birth certificate or proof of birth from hospital/ clinic. Note: babies must be registered within 90 days of birth. Copy of ID. Membership certificate from previous medical scheme (if applicable). Copy of ID. Proof of full-time studies (if applicable). Affidavit, stating that child is not self-supporting. Membership certificate from previous medical scheme (if applicable). Copy of ID. Debit order authorisation (contributions; if applicable). Copy of latest bank statement or affidavit of financial means. Copy of ID. Copy of death certificate. Debit order authorisation (contributions; if applicable). Copy of latest bank statement or affidavit of financial means.

Husband/Wife

Child Dependant; up to the age of 21

Dependant; aged 21 and over (see below)

Continuation of membership

Widow(er)

KEYHEALTH MEMBER GUIDE 2012

055

WHO
Disabled Dependant Legally adopted child Child born before/out of wedlock (if surname differs) Stepchild Special Dependant

WHAT
Copy of ID. Copy of death certificate of late parent(s). Debit order authorisation (contributions; if applicable). Copy of latest bank statement or affidavit of financial means. Official documents confirming continuation of membership. Copy of ID. Proof of disability from Medical Practitioner. Copy of birth certificate. Copy of final adoption order. Copy of ID. Affidavit, confirming co-habitation. Membership certificate from previous medical scheme (if applicable). Copy of birth certificate or proof of birth from hospital/ clinic. Affidavit that child is the biological child of the Principal Member. Note: babies must be registered within 90 days of birth. Copy of birth certificate. Affidavit that child is the biological child of the Principal Members Spouse/Partner. Membership certificate from previous medical scheme (if applicable). Copy of ID. Proof of income, or Affidavit stating financial dependency on the Principal Member. Membership certificate from previous medical scheme (if applicable).

Orphan

Members Partner

Please note: Where applicable, always complete the Medical Details section of the application form in full and correctly.

056

KEYHEALTH MEMBER GUIDE 2012

Individuals of the Principal Members family / household / family group qualifying for registration as Dependants:
A Spouse to whom the Principal Member is married in terms of any recognised South African law or custom. A recognised Life Partner of the Principal Member, irrespective of sex. The Principal Members own, step- or legally adopted child who is not receiving a regular income of more than the current Social Pension. Anyone of the Principal Members immediate family (i.e. parents, in-laws, grandchildren, brothers or sisters) for whom the Principal Member is responsible to provide financial support is regarded as a Special Dependant. Please note: None of the above should be an existing beneficiary of any registered medical scheme.

Dependant; 21 years and older:


A Dependant of 21 years and older could be the Principal Members own (biological), step- or legally adopted child, but always keep the following in mind: - A Disabled Dependant (proof of disability provided by a registered Medical Practitioner), whatever his/her age, will be regarded as a Child Dependant.

Dependant; 21 years and older, but not yet 25 years of age:


The Dependant is regarded as an Adult Dependant if he/she is not self-supporting (i.e. does not receive a fixed income of equal to or more than the current Social Pension) and is thus financially fully dependent on the Principal Member. The Dependant is regarded as a Child Dependant if he/she is not self-supporting and if official proof of full-time studies at a recognized national educational institution is provided (annually). If the Dependant is self-supporting, then his/her Scheme membership will be terminated and he/she could apply for principal membership with KeyHealth or any other registered medical scheme.

Dependant; 25 years and older:


The Dependant is regarded as an Adult Dependant if he/she is not self-supporting (i.e. does not receive a fixed income of equal to or more than the current Social Pension) and is thus financially fully dependent on the Principal Member. Under all other circumstances, this Dependants membership will be terminated and he/she could apply for principal membership with KeyHealth or any other registered medical scheme.

KEYHEALTH MEMBER GUIDE 2012

057

Insurability:
Proof of health is provided when the Principal Member completes the Medical Details section on the application form and signs the form (where applicable). According to legislation, the Scheme is entitled to request a health certificate for any applicant (Principal Member and/or Dependant), where applicable. Please note: It is important to disclose each applicants full medical history as this will prevent possible rejections and/or further actions because of non-disclosure.

4.2|UNDERWRITING
If a Principal Member and/or Dependant suffers from a specific illness, the Scheme has the right to exclude benefits for this specific condition for a period of up to twelve (12) months. Subject to the Rules, the Scheme may impose upon a person in respect of whom an application is made for membership or admission as a Dependant, and who was not a beneficiary of a medical scheme for a period of at least ninety (90) days preceding the date of application: - a General Waiting Period of up to three (3) months, including PMB conditions; and - a Condition-specific Waiting Period of up to twelve (12) months, including PMB conditions. The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a Dependant, and who was previously a beneficiary of a medical scheme for a continuous period of up to twenty-four (24) months, terminating less than ninety (90) days immediately prior to the date of application: - a Condition-specific Waiting Period of up to twelve (12) months, except in respect of any treatment or diagnostic procedures covered within PMB conditions; and - in respect of any person contemplated, where the previous medical scheme had imposed a General or Condition-specific Waiting Period, and such waiting period had not expired at the time of termination, a General or Condition-specific Waiting Period for the unexpired duration of such waiting period imposed by the former medical scheme.

058

KEYHEALTH MEMBER GUIDE 2012

The Scheme may impose upon any person in respect of whom an application is made for membership or admission as a Dependant, and who was previously a beneficiary of a medical scheme for a continuous period of more than twenty-four (24) months, terminating less than ninety (90) days immediately prior to the date of application: - a General Waiting Period of up to three (3) months, except in respect of any treatment or diagnostic procedures covered within PMB conditions.

Late joiner penalty:


A premium loading (late joiner penalty) may be imposed on an applicant (Principal Member and/or Adult Dependant) aged 35 and over, who was not a member or dependant of one or more recognised medical scheme from a date before 1 April 2001 and without a break in coverage exceeding three (3) consecutive months since 1 April 2001. This loading is calculated according to the years spent without medical scheme coverage after reaching the age of 35, with credit given for years of cover after reaching the age of 21, according to the following table: 1 5 15 to to to <5 years at 5% <15 years at 25% <25 years at 50% 25 years at 75%

Non-disclosure consequences:
If found that false information has been submitted or that any relevant information has deliberately been omitted on an application, the Scheme may correct this in terms of its Rules, which may include re-underwriting or termination of membership.

Membership in the course of the benefit year:


When joining the Scheme in the course of a benefit year (between 01 Jan. and 31 Dec.), the Beneficiary will receive pro rata benefits, i.e. annual maximum on benefits will be reduced according to the number of months left in the benefit year across all benefit categories.

Membership cards:
Principal Members with one or more Dependant are provided with two (2) membership cards. Principal Members without Dependants are provided with one (1) membership card.

KEYHEALTH MEMBER GUIDE 2012

059

A membership card, presented on request to the service provider (e.g. a General Practitioner), is proof that the holder is a registered Scheme member. A membership card remains the property of the Scheme and must be destroyed when membership is terminated. A membership card may never be used by anyone other than the Principal Member or his/her registered Dependants. Keep membership cards in a safe place.

The contents of a member pack:


Welcome letter containing member-specific information regarding the Scheme and which must be checked by the Member for accuracy and completeness. Member Guide a booklet containing important information regarding membership and the Scheme Rules. Member card(s) containing the following information and which must be checked by the Member for accuracy and completeness: Membership number; Enrolment date; Benefit date; Name(s) and surname(s) of Principal Member and registered Dependant(s); Dependant code(s); Identity numbers of the Principal Member and registered Dependant(s);

Other documentation: Netcare 911 sticker.

4.3| MEMBERSHIP CHANGES


Please note: Requests submitted for option changes must be done by completing and submitting the Schemes official Option Change Form. This form is available on the Schemes website at www.keyhealthmedical.co.za or by contacting the Client Service Centre on 0860 671 050.

060

KEYHEALTH MEMBER GUIDE 2012

A Member joining the Scheme has the right to change benefit option within the first three (3) months:
The change will be effective from the date of joining, with backdated correction of membership fees and claims submitted.

Normal benefit option changes:


An option change is only allowed at the end of each benefit year, effective as from 1 January the following year. The request to change benefit option the following year must be submitted to the Scheme by 15 December of the previous year.

Inform the Scheme within thirty (30) days in the event of any of the following changes to membership details:
Registration of new dependant(s). Dependant(s) no longer qualifying for membership. Contact details (postal address, telephone number, fax number, cell number and e-mail address). Banking details (include the latest bank statement or an official letter from the bank), indicating whether the change is applicable to claims refund or contribution deduction.

4.4| RETIREMENT / DEATH OF PRINCIPAL MEMBER


Principal Member subsidised by employer:
A Principal Member should give at least one (1) months written notice to the Scheme regarding retirement and whether membership will be continued. A Principal Member, who receives a subsidy from an employer, needs to confirm whether the subsidy will continue after retirement. If not, the Member will be responsible for the full contribution amount. A Principal Member who retires may request to change benefit option, effective from the date of retirement.

KEYHEALTH MEMBER GUIDE 2012

061

Upon death of the Principal Member:


Notify the Scheme as soon as possible of the Principal Members death and submit a copy of the death certificate. Unless the Scheme is otherwise informed, the eldest Dependant shall be admitted as the Principal Member. Principal Member fees shall be applicable from the first day of the month following the Principal Members death, irrespective of age. The membership number remains unchanged when the Spouse/Partner becomes the Principal Member, and new card(s) will be issued. Adjusted membership contributions are paid without interruption. In all other instances a new membership number and new card(s) will be issued.

Retirement (continuation of membership):


Mail notification of change to Membership at: KeyHealth Medical Scheme P Box 14145 .O. Lyttelton 0140 Fax: 0860 111 390 No change will be implemented retrospectively. Please remember to state the Principal Members full name, surname and membership number on the letter/fax.

4.5| CONTRIBUTIONS
Date of payment:
Contributions are payable in arrears for Local Authority members and in advance for all other Members. - Contributions, payable in arrears, must be paid by the end of each month: Example: Contributions for January must be received by 31 January. - Contributions, payable in advance, must be paid by the 7th of each month: Example: Contributions for January must be received by 7 January.

062

KEYHEALTH MEMBER GUIDE 2012

Adjustment to contributions:
If contributions are adjusted due to the registration of an additional Dependant, the adjusted fees are payable as from the first day of the month of the new registration. Please note: Benefits for such a Dependant will apply from the date of membership, provided that all conditions have been met. If contributions are adjusted due to the registration of a newborn baby Dependant, the adjusted fees are payable as from the first day of the month following the babys date of birth. Please note: Benefits for such a Dependant will apply from the date of birth, provided that all conditions have been met.

Method of payment:
Contribution payments can only be made into the following bank account: Bank Name of Account Holder Account Number Reference Number | | | | ABSA KeyHealth Medical Scheme 6 000 000 12 Membership Number

Please do NOT mail cash or cheques. The Scheme does NOT accept any responsibility if cash or cheques get lost in the mail. It is very important that Members use their membership number as reference for ALL deposits made to / correspondence with the Scheme. Please fax proof of payment to 0860 111 390, attention: Scheme Finance.

KEYHEALTH MEMBER GUIDE 2012

063

4.6| TERMINATION OF MEMBERSHIP


Termination of a Principal Members membership:
On resignation of the Principal Member from an employer (where membership was a condition of service and the Principal Member did not opt to retain it). Upon death of the Principal Member. When the Scheme receives one calendar months notice of cancellation from the Principal Member/employer. When a Principal Member no longer qualifies for membership in terms of any other stipulation as contained in the latest Scheme Rules. If the Scheme finds that a Principal Member and/or Dependant(s) have misused benefits.

Termination of a Dependants membership:


When the Principal Members membership is terminated. When the Principal Member notifies the Scheme to terminate membership of a Dependant [at least one (1) calendar months written notice].

Certificate of membership:
On termination of membership, the Scheme will furnish a certificate of membership.

Re-instatement of membership:
A Member may apply for re-instatement of membership within thirty (30) days of the termination date. Such an application must be accompanied by a Declaration of Health to determine any underwriting. A Member terminated due to outstanding debt may apply for re-instatement within thirty (30) days from the date of notification of termination, provided that all outstanding debts are settled. Such application must be accompanied by a Declaration of Health to determine any underwriting.

05 | PRESCRIBED MINIMUM BENEFITS (PMBs)

066

KEYHEALTH MEMBER GUIDE 2012

05| PRESCRIBED MINIMUM BENEFITS (PMBs)


Definition:
PMBs are defined by the Medical Schemes Act with the aim to ensure that all medical scheme beneficiaries have access to certain minimum health benefits, regardless of the scheme benefit option they have chosen, their age or the state of their health. In terms of the Act, medical schemes have to cover the costs related to the diagnosis, treatment and care of: - all emergency medical conditions; and - a limited set of approximately 270 medical conditions as defined in the Diagnosis Treatment Pairs, which includes 25 chronic conditions as defined in the Chronic Disease List. The treating Doctor decides whether a condition is a PMB or not by taking into account the symptoms only a diagnosis-based approach.

Conditions that are covered:


In Annexure A of the Regulations to the Medical Schemes Act, the complete list of PMB conditions is provided in the form of Diagnosis and Treatment Pairs. The approximately 270 conditions qualifying for PMB cover are diagnosis-specific and include a large number of diverse conditions, broadly divided into 15 categories:

PMB Category
Brain and nervous system Eye Ear, nose and throat Respiratory system Heart and vascular system (blood vessels) Gastro-intestinal system Liver, pancreas and spleen Musculoskeletal system (muscles and bones) Skin and breast Endocrine, metabolic and nutritional system Urinary and male genital system

Example
Stroke Glaucoma Cancer of oral cavity, pharynx, nose, ear and larynx Pneumonia Heart attack Appendicitis Gallstones Fracture of the hip Treatable breast cancer Disorders of the parathyroid gland End-stage kidney disease

KEYHEALTH MEMBER GUIDE 2012

067

PMB Category
Female reproductive system Pregnancy and childbirth Haematological, infectious and miscellaneous systemic conditions Mental conditions

Example
Cancer of the cervix, ovaries and uterus Antenatal and obstetric care requiring hospitalisation, including delivery HIV/Aids and TB Schizophrenia

The Chronic Disease List (CDL) specifies the 25 chronic conditions that are covered (see below). Please note: PMBs are not influenced by Scheme exclusions.

ICD-10 codes:
A PMB condition can only be correctly identified by indicating the appropriate ICD-10 code. It is thus of the utmost importance that the correct ICD-10 codes are used in order to ensure that PMB-related services are paid from the appropriate benefits or paid at all. The correct ICD-10 codes must also appear on the relevant medicine prescriptions and referral notes to other healthcare service providers. In accordance with the Act, healthcare service providers are not allowed to retrospectively change ICD-10 codes, which have already been submitted to the Scheme. In cases where such codes are changed by service providers, the Scheme will not re-process the affected claims.

Emergency:
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or intervention. If the treatment/ intervention is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death.

PRESCRIBED MINIMUM BENEFIT (PMB) CHRONIC DISEASE LIST (CDL)


1. 2. 3. 4. 5. 6. 7. 8. Addisons Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy Disease Chronic Renal Disease Coronary Artery Disease 14. 15. 16. 17. 18. 19. 20. 21. Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hyperthyroidism Multiple Sclerosis Parkinsons Disease

068

KEYHEALTH MEMBER GUIDE 2012

PRESCRIBED MINIMUM BENEFIT (PMB) CHRONIC DISEASE LIST (CDL) (Continued)


9. Crohns Disease 10. Chronic Obstructive Pulmonary Disorder 11. Diabetes Insipidus 12. Diabetes Mellitus Type 1 & 2 13. Dysrhythmias 22. 23. 24. 25. Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosis Ulcerative Colitis

Subject to application and approval, the Scheme will pay 100% of MST in respect of any services which are voluntarily obtained by a Beneficiary from a service provider other than the DSP for a PMB condition. Subject to application and approval, any services in respect of PMBs which are involuntarily obtained by the Beneficiary from a service provider other than the DSP will be covered in full. (*) , A Beneficiary will be deemed to have involuntary obtained a service from provider other than the DSP if: , - the service was not available from the DSP or would not be provided without unreasonable delay; - immediate medical or surgical treatment for a PMB condition was required under circumstances or at locations which reasonably precluded the Beneficiary from obtaining such treatment from a DSP; or - there was no DSP within reasonable proximity of the Beneficiarys ordinary place of business or personal residence. Except in the case of an emergency medical condition, pre-authorisation shall be obtained by a Member prior to involuntary obtaining a service from a provider other than a DSP in terms of this paragraph to enable the Scheme to confirm that the circumstances contemplated in paragraph (*) above are applicable.

DSPs for PMBs: Any service falling within the PMBs and rendered by the Schemes Designated Service Provider (DSP) will be covered in full. The Scheme has appointed the following DSPs in respect of hospitalisation:
The National Hospital Network (NHN). The State Hospitals (Gauteng, Free State and Western Cape) as the DSP for any major medical services which fall within PMBs. In the absence of any formal agreement, any other hospital will be regarded as a DSP . CareCross Specialist Network. (This network will also be applicable to out-of-hospital, PMB related services. Details of Specialists on the network may be obtained from the Authorisation Call Centre on 0860 671 060. A full list will also be available at www.keyhealthmedical.co.za.)

KEYHEALTH MEMBER GUIDE 2012

069

NOTES:

06 | MEDICATION

072

KEYHEALTH MEMBER GUIDE 2012

6.1| PRESCRIBED ACUTE MEDICATION


Acute medication is once-off medication, prescribed by a Medical Practitioner for conditions not recognised as chronic by the Scheme. Medication, as per the Schemes exclusion list, is excluded. Acute medication is subject to the application of MMAP (Maximum Medical Aid Price). Please note: Homeopathic medicine is subject to the acute (day-to-day) benefits.

Where to obtain acute medication:


Acute medication may be obtained from any pharmacy or from a dispensing Medical Practitioner.

Medication on discharge from a hospital:


Medication provided to a Beneficiary upon discharge from a hospital is limited to the following: PLATINUM GOLD SILVER EQUILIBRIUM ESSENCE R385 per admission R335 per admission R165 per admission R335 per admission R275 per admission

If only a prescription for medication is received upon discharge from the hospital, the medication thus obtained will be paid from the day-to-day benefit and does not qualify as medication on discharge.

KEYHEALTH MEMBER GUIDE 2012

073

6.2| MAXIMUM MEDICAL AID PRICE (MMAP)


MMAP is a guideline to determine the maximum price the Scheme is prepared to pay for specific medical products. MediKredit, a service provider of the Scheme, determines the MMAP levels by conducting surveys in the medicine market and is responsible for the compilation and updating of MMAP. Products covered in the MMAP directive have been chosen because they have been tried, tested and approved by the Medicine Control Council. The approval is based on evaluation criteria which determine that a product may be regarded as the pharmaceutical equivalent (also known as generic equivalent) of an established branded medicine. The composition and medicinal effect of generic products are thus the same, but may differ in price. If a prescribed product is priced above the MMAP, the Beneficiary will need to pay the difference in price at the point of dispensing. Should the Beneficiary choose to receive the MMAP product, priced within the permitted limits, the Scheme will pay the full price of this product (excluding any possible levies that may be applicable). To manage benefits effectively and to affect cost savings, Beneficiaries are advised to request the Medical Practitioner, where possible, to prescribe generic medication.

6.3| OVER-THE-COUNTER MEDICATION


Over-the-counter medication (self-medication) is medication with a NAPPI code that can be obtained from a pharmacy without a prescription. For over-the-counter benefits on all options, see the Benefit Structure in chapter 3 of this Member Guide. These are typical cold and flu type medicine, such as cough medicine and decongestants. These include vitamins, and Schedule 1 and 2 medication. The pharmacy either claims the amount due directly from the Scheme, or the Beneficiary pays the pharmacy in cash and submits the claim, which should include the name, quantity, price and NAPPI code of each item of medication, and proof of payment of such account.

074

KEYHEALTH MEMBER GUIDE 2012

6.4| REGISTRATION FOR CHRONIC CONDITIONS AND PRESCRIBED CHRONIC MEDICATION


Prescribed chronic medication is used continuously for three (3) months or more for conditions as contained in Table 1 (Category A) and/or Table 2 (Category B) (see subsection 6.6). If a patient is diagnosed with one of the chronic conditions listed in Table 1 or Table 2, then registration of the chronic condition involved is required before access to the chronic medication benefit will be granted. No authorisation forms are involved, as this is a paperless process, unless there are specific test results and/or a motivation required. Only new condition registrations require the Doctor or Pharmacist to intervene. Chronic conditions already registered with the Scheme, require no action at the start of the new benefit year, as existing chronic conditions will automatically remain registered. Authorisation for chronic medication is subject to the following: - The treating Doctor or the Pharmacist (after the initial consultation with the Doctor) must register chronic conditions with MediKredit on 0800 132 345, as detailed clinical information, including the conditions ICD-10 code and severity status is required. - The Doctors prescription will then authorise the patient the right to obtain the chronic medication from a local pharmacy, a Scheme DSP pharmacy or the Doctors dispensary. - Certain products can only be authorised if prescribed by the appropriate Specialist. These Specialists must contact MediKredit on 0800 132 345 for further information.

6.5| THE CONDITION MEDICINE LIST (CML)


The CML (Condition Medicine List) is a Scheme approved list of clinical appropriate medicine used for the treatment of a particular condition, i.e. each condition has a CML. Chronic conditions are classified as PMB or non-PMB conditions. The CML is not a fixed list of products, but is continuously being revised with regard to new products being registered, products that no longer exist, price changes, MMAP changes, as well as changes to the product registration details for a condition.

KEYHEALTH MEMBER GUIDE 2012

075

The CML does not contain all medication that may possibly be required to treat a patients condition, as some medication requires a specific authorisation. This authorisation will be limited to a specific period, depending on the prescription and the motivation from the treating Doctor/Specialist. Please refer to MediKredit on the KeyHealth website on www.keyhealthmedical.co.za for chronic conditions, updated products and prices, as well as possible alternatives at lower prices. This search facility also indicates at a product level whether co-payments apply.

Formulary medicine:
According to legislated therapeutic algorithms (treatment plans), the Scheme makes use of medicine formularies (medicine lists) for chronic medication by focusing on the management of cost and ensuring accessibility and appropriate care to all Beneficiaries. These formularies are approved lists of medication for each of the 26 chronic conditions covered by the Scheme and do not compromise the quality of healthcare the Beneficiary receives. These medicines are included with the CML and are available to all patients with the specified condition to which no reference price applies, provided they are claimed in appropriate quantities.

Non-formulary medicine:
Reference pricing may be applied to non-formulary medicine for both PMB CDL and non-PMB CDL conditions, in accordance with the benefit selected by the Beneficiary (refer to details discussed under Reference Price below).

6.6| REFERENCE PRICE


Reference price is the maximum amount that the Scheme is willing to pay for medicine from a similar medicine class listed on the Condition Medicine List for that condition. This reference price may differ on each benefit option. Reference price is about patient choice. Medicine priced above the reference price may be substituted with a clinically appropriate alternative product (a generic substitute),

076

KEYHEALTH MEMBER GUIDE 2012

where applicable, that is less expensive and does not incur any additional out-of-pocket costs. However, if the Beneficiary chooses to remain on the existing, more expensive product when appropriate alternatives are available, a co-payment will apply. Reference price is reviewed once a year. This review process considers all the new medicine entries during the year, medicine discontinuations, new enhancements, clinical literature, licensed indications, price changes, generic influence, patent expiry etc. Please refer to MediKredit on the KeyHealth website at www.keyhealthmedical.co.za to determine the reference price of the medicine currently used. If the medicine displayed on the screen is above reference price, the Beneficiary will then be required to pay a co-payment at the point of dispensing. The reference price is based on the cost of medicine from a similar drug class listed on the formulary to which no reference price applies. The Beneficiary is required to pay the difference between the cost of the medicine and the reference price of the formulary medicine at the point of dispensing. Please note: If certain medicine is still not authorised after intervention by the Doctor/Specialist, or the condition being treated does not fall under Table 1 or 2, the Beneficiary can obtain the medicine from a local pharmacy or a dispensing Doctor and claim it against the available day-to-day benefits, if applicable. TABLE 1 (CATEGORY A): PRESCRIBED MINIMUM BENEFIT (PMB) CHRONIC DISEASE LIST (CDL) (ALL OPTIONS)

PRESCRIBED MINIMUM BENEFIT (PMB) CHRONIC DISEASE LIST (CDL)


1. Addisons Disease 2. Asthma 3. Bipolar Mood Disorder 4. Bronchiectasis 5. Cardiac Failure 6. Cardiomyopathy Disease 7. Chronic Renal Disease 8. Coronary Artery Disease 9. Crohns Disease 10. Chronic Obstructive Pulmonary Disorder 11. Diabetes Insipidus 12. Diabetes Mellitus Type 1 & 2 13. Dysrhythmias 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hyperthyroidism Hormone Replacement Therapy (HRT)(*) Multiple Sclerosis Parkinsons Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus Erythematosis Ulcerative Colitis

(*) Indicates an additional chronic condition approved by the Scheme.

KEYHEALTH MEMBER GUIDE 2012

077

6.7| OTHER CHRONIC CONDITIONS (PLATINUM OPTION)


TABLE 2 (CATEGORY B): OTHER CHRONIC CONDITIONS (PLATINUM OPTION ONLY)

OTHER CHRONIC CONDITIONS


1. Acne 2. Allergic rhinitis 3. Alzheimers disease 4. Ankylosing spondylitis 5. Benign prostatic hypertrophy 6. Clotting disorders(#) 7. Cystic fibrosis 8. Deep vein thrombosis(#) 9. Diverticulitis and Irritable bowel syndrome 10. Gastro-esophageal reflux disease 11. Hypoparathyroidism(#) 12. Hyperkinesis (ADD - Attention Deficit Disorder) 13. Hyperthyroidism 14. Interstitial fibrosis 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. Iron deficiency anemia Major depression(#) Menieres disease Menopausal disorder (Calcium only)(#) Migraine Myasthenia gravis Osteoarthritis Osteoporosis Paraplegia, quadriplegia(#) Peripheral vascular disease(#) Psoriasis Rheumatic fever Stroke(#)

28. Testosterone deficiency 29. Urinary incontinence

Chronic medication for PMB conditions indicated with (#) (only for severe life threatening cases and motivated by the appropriate Specialist) will be paid at 100% of the cost at a DSP pharmacy. 10% co-payment on chronic medication for non-PMB conditions. Please note: Additional co-payments may be incurred if the price of products used is higher than the reference price/MMAP. Managed Health Care protocols apply to all conditions.

078

KEYHEALTH MEMBER GUIDE 2012

6.8| BIOLOGICAL MEDICATION


The following protocols will be applicable to the use of biological medication by Beneficiaries:

6.8.1| PMB (on Algorithm), e.g. multiple sclerosis:


Will be paid for by the Scheme on all options; No co-payment will be applicable if obtained from a Scheme DSP; When the medication is obtained from a non-DSP the following co-payments will apply: , - 10% co-payment on the Platinum option; - 15% co-payment on the Gold option; - 30% co-payment on the Silver, Equilibrium and Essence options.

6.8.2| PMB (not on Algorithm), e.g. rheumatoid arthritis, Crohns disease and ulcerative colitis:
Applicable to the Platinum option only; 10% co-payment when medication is obtained from a non-DSP; Payable from the chronic benefit and then from risk.

6.8.3| Diagnoses Treatment Pairs (DTP) Conditions:


Applicable to all options; The interpretation of DTP will be in accordance with the Performance Health (PH) protocols, including investigation of the availability in State facilities; When the medication is obtained from a non-DSP the following co-payments will apply: , - 10% co-payment on the Platinum option. - 15% co-payment on the Gold option; - 30% co-payment on the Silver, Equilibrium and Essence options;

6.8.4| Chronic Conditions:


Platinum option only; 10% co-payment applicable when using a non-DSP; 10% co-payment not applicable to PMB conditions; Annual chronic limit applies; If also a DTP and the medication is eligible as per PH protocols:

KEYHEALTH MEMBER GUIDE 2012

079

Once the annual chronic limit has been exceeded, the provider must contact MediKredit for DTP authorisation. Thereafter, rules and co-payments apply as per 6.8.3 above.

6.8.5| Section 21 and Medication Used Alternatively (off-label):


Managed on a case-by-case basis and in accordance with the PH protocols; Clinical Committee to approve level of funding based on cost effectiveness compared to alternate registered therapy; Maximum of 30% co-payment will be applicable to all options.

6.8.6| Oncology:
Medication for treatment will be considered in accordance with the South African Oncology Consortium (SAOC) guidelines and protocols: - Tier 3 30% co-payment. Platinum option only. - Tier 2 (State facilities) no co-payment. All options. - Tier 2 (not in State facilities) Platinum option no co-payment. Other options - co-payment. - Tier 1 All options - no co-payment.

080

KEYHEALTH MEMBER GUIDE 2012

6.9| DSP PHARMACIES


Agreements have been reached with pharmacies throughout South Africa for the supply of medication to KeyHealth Beneficiaries at reduced rates. The list below shows only the nationwide DSP pharmacies. For a comprehensive list, visit www.keyhealthmedical.co.za or contact the KeyHealth Client Service Centre on 0860 671 050.

SUPPLIER
Chronic Medicine Dispensary Clicks Pharmacy Direct Medicines clicks.directmedicines@dirmed.co.za Dis-Chem Medipost keyhealth@medipost.co.za MediRite Pharmacies mediritechronic@shoprite.co.za

WEBSITE
www.chronicmedicine.com www.clicks.co.za www.directmedicines.co.za www.dischem.co.za www.medipost.co.za www.medirite.co.za

TELEPHONE
0860 633 420 0860 254 257 0861 444 405 0800 201 170 012 426 4075 012 426 4076 0800 010 709

Chronic medicine obtained from a non-DSP pharmacy:


The Scheme will pay 100% up to the reference price for chronic medication, and the following co-payments will apply: PLATINUM GOLD SILVER EQUILIBRIUM ESSENCE 10% 15% 30% 30% 30%

Please note: HIV/Aids medicine must be obtained from First Care Courier Pharmacy. Should Members choose to obtain this medicine from any other pharmacy; the Scheme will not be responsible for the payment thereof.

KEYHEALTH MEMBER GUIDE 2012

081

6.10|CHRONIC MEDICATION ON TRAVELLING ABROAD


To qualify for additional chronic medicine for use during a foreign visit (up to a maximum of 90 days without interruption), the Principal Member involved must inform the Scheme in writing at least one (1) month in advance of the following: - The full name and surname, and the dependant code of the Beneficiary(ies) who will be undertaking the planned foreign visit; - The name(s) of the country(ies) to be visited; - The starting and end date of the visit; - The name(s) of the additional chronic medicine required and the quantities involved. Upon receipt of the necessary chronic information, the Scheme will issue the Beneficiary, bound to travel abroad, with a letter of confirmation to be utilised by the Pharmacist to release and claim for the chronic medicine involved. The Beneficiary(ies) planning to travel abroad and who will require additional chronic medication, must then request their Pharmacist to contact MediKredit at least fourteen (14) days prior to departure on 0800 132 345 to make the necessary arrangements.

07 | HOSPITALISATION & MANAGED HEALTHCARE

084

KEYHEALTH MEMBER GUIDE 2012

7.1| AUTHORISATION OF HOSPITAL ADMISSIONS


Before admission to hospital, the Member must phone 0860 671 060 (Authorisation Call Centre) for the necessary authorisation. The following information must be provided when calling: - Membership number; - The full name and surname, and dependant code of the patient being hospitalised; - The name and practice number of the hospital to which the patient will be admitted; - The reason for the hospital admission: > Admission diagnoses or ICD-10 code; > If admission is for planned surgery, all relevant procedure (tariff) codes; > CPT4 codes, if available. - The date of admission and scheduled date of the procedure; - The practice number of: > The treating Doctor/Specialist; > The referring Doctor/Specialist; > Other service providers (if applicable); > Alternatively, the initials, surname and telephone number of both treating and referring Doctor/Specialist. - The expected length of stay in hospital. Please note: - Authorisation does not guarantee that all associated costs of the authorised procedure will be paid. - Benefits will be paid according to what is permitted in terms of the Scheme Rules. - Services must commence within thirty (30) days of approval and will be subject to the available benefits of the year in which the services are rendered. - The Beneficiary enjoys the particular benefits for as long as hospitalisation of the case involved has been authorised. Before and after hospitalisation, the Beneficiary receives out-of-hospital benefits. Authorisation needs to be obtained within 24 hours prior to an admission, or within two (2) working days after an emergency admission (family members, friends or the hospital can call on behalf of the Beneficiary, if he/she is unable to), otherwise no benefits will be paid.

KEYHEALTH MEMBER GUIDE 2012

085

Should Members receive accounts requesting additional payments for hospitalisation, kindly contact the Client Service Centre on 0860 671 050 for verification prior to making payments.

7.2| DISEASE / CASE MANAGEMENT


The programmes below are all subject to case management.

7.2.1| Registration
If a Beneficiary does not register on an appropriate Disease Management Programme, available day-to-day benefits will be applicable.

7.2.2| Oncology
The Doctor/Specialist must complete a South African Oncology Consortium (SAOC) treatment plan or write a prescription for associated oncology medication to: - Effect registration on the programme; - Facilitate the evaluation and final approval of treatment; - Ensure timely processing of cancer related claims. Fax the treatment plan to 012 679 4469. Call 0860 671 060 for specific authorisation in respect of: - Chemotherapy treatment at the Doctors/Specialists facility; - Chemotherapy treatment during hospitalisation and on an outpatient basis at the hospital; - Radiotherapy, MRI, CT and PET scans, consultations and blood tests. Oncology follow-up management programme: - Upon the treating Doctors/Specialists completion of the oncology treatment plan, Beneficiaries must register with the Schemes Oncology Case Manager on 0860 671 060 to manage follow-up treatments related to the original diagnosis. - Approved consultations and medication related to the original diagnosis will not be subject to the day-to-day benefits of the member, but to available oncology benefits.

086

KEYHEALTH MEMBER GUIDE 2012

7.2.3| Organ transplants and dialysis


Organ transplants and dialysis require authorisation and are subject to: - Limits as described in the Benefit Structure section of this Member Guide; - Case management.

7.2.4| Diabetes
Newly diagnosed diabetes: - Beneficiaries may visit the Doctor of their choice for these services; - The treating Doctor must register the condition with MediKredit on 0800 132 345.

7.2.5| HIV/AIDS
The Scheme has contracted with LifeSense Disease Management to manage the HIV/Aids Programme. Registering on the HIV/Aids Programme: - Contact LifeSense Disease Management on 0860 506 080; - Beneficiaries may visit the Doctor of their choice for the initial examination; - The treating Doctor will complete the application form in co-operation with the Beneficiary and forward the form and results of any blood test to LifeSense; - A treatment plan, submitted by the treating Doctor and based on the above information, will have to be approved by the Medical Advisor of LifeSense; - The Beneficiarys Doctor will be contacted by LifeSense and advised what medication options are available, taking in consideration the stage of the disease. Utilisation of the HIV/Aids Programme: - Once the Beneficiary is enrolled on the programme, the treating Doctor will be contacted on a regular basis by the LifeSense Case Manager; - Assistance will be provided to support and reinforce the importance of the correct utilisation of the authorised medication; - The Beneficiary will also be assisted with lifestyle adjustments and counseling. Direct enquiries related to HIV/Aids claims to the Client Service Centre on 0860 671 050.

KEYHEALTH MEMBER GUIDE 2012

087

7.3| MATERNITY
Pre-notification and pre-authorisation are essential in order to qualify for maternity benefits on Health Booster. Call 0860 671 050 to ensure that the pregnant Beneficiary will receive a complimentary pregnancy and birth book. Call 0860 671 060 at least one (1) week before a caesarian section or delivery (if possible), or within 48 hours after childbirth for authorisation with regard to the delivery.

7.4| MEDICAL APPLIANCES


Medical appliances can be described as medical equipment used for the treatment and cure of medical conditions. The medical appliance benefit includes items such as wheelchairs, orthopedic appliances, incontinence equipment (including nappies for adults) and contraceptive devices. Authorisation is necessary for all medical appliances. For authorisation, fax the Medical Practitioners motivation as well as a quotation to 012 679 4471 (attention: Medical Appliances).

7.5| PROSTHETICS
Prosthesis (an artificial body part) is an artificial replacement of an internal or external part of the body, such as a hip or knee joint, a leg, an arm, a heart valve etc. Pre-authorisation is compulsory for all external and internal prosthesis by contacting 0860 671 060, and faxing a quotation to 012 679 4471 (attention: Prosthetics).

088

KEYHEALTH MEMBER GUIDE 2012

7.6| OUTPATIENTS
The Beneficiarys choice
If the Beneficiary chooses to consult the outpatient facility of a hospital during hours when General Practitioners are normally available (and in some instances also for conditions not classifiable as trauma / an emergency / a PMB), it is generally an expensive choice of which the costs are not necessarily covered by any Scheme benefits.

When will an outpatient visit be covered by Scheme benefits?


An outpatient visit, as a result of a confirmed emergency / trauma / PMB condition, and which leads to: - a recognised medical procedure at the emergency facility or the subsequent admission to the/a hospital, and for which Scheme authorisation is obtained immediately or within 48 hours / on the first working day after a weekend; will be considered for recovery from the Members relevant benefits.

Please note: Expenses incurred in respect of outpatient visits not covered by the Scheme, may be paid upon request from available medical savings.

KEYHEALTH MEMBER GUIDE 2012

089

NOTES:

08 | DENTAL BENEFITS

092

KEYHEALTH MEMBER GUIDE 2012

8.1| DENIS CONTACT DETAILS


DENIS [Dental Information Systems (Pty) Ltd] manages Beneficiaries dental benefits on behalf of the Scheme. The Scheme pays benefits for dental treatment up to a specified percentage of MST. This may differ from the fees charged by Dentists. KeyHealths dental benefits can be viewed at www.denis.co.za. DENIS important contact details: Call Centre telephone number Call Centre fax number E-mail address for enquiries E-mail address for claims E-mail address for DENIS authorisations E-mail address for crowns E-mail address for periodontics E-mail address for orthodontics and implants | | | | | | | | 0860 104 926 0866 770 336 keyhealthenq@denis.co.za claims@denis.co.za auths@denis.co.za crowns@denis.co.za perio@denis.co.za ortho@denis.co.za

Paper claims must be submitted to the following address: DENIS Private Bag X1 CENTURY CITY 7446 (See the Benefit Structure in this Member Guide for the Dental Benefits.)

8.2| GENERAL DENTAL INFORMATION


Benefit pre-authorisation is compulsory for any Specialised Dentistry Dental treatment. Contact the DENIS Call Centre on 0860 104 926 to obtain the necessary pre-authorisation. Please note: If no pre-authorisation is obtained or if pre-authorisation is applied for after the treatment has been begun, no benefit for such treatment will be paid. This does not apply to emergency hospital admissions.

KEYHEALTH MEMBER GUIDE 2012

093

Crowns and Bridges: - A crown (cap) is an artificial restoration (hard cover) which is made to fit over a badly damaged or decayed tooth. - A bridge is made to replace one or more missing teeth. It is an alternative to a partial denture and usually used where there are fewer teeth to replace, or when the missing teeth are only on one side of the mouth. - Benefits for crowns are subject to pre-authorisation, where DENIS protocols apply. - All pre-authorisation requests for crown and bridge benefits must be accompanied by clinical records (treatment plans and clear X-rays of the teeth to be treated). - Clinical records must be faxed to DENIS on 0866 770 336, or e-mailed to crowns@denis.co.za. Orthodontics (braces) - Benefits for orthodontic treatment will be granted where function is impaired and are based on DENIS protocols. - Benefits will not be granted where orthodontic treatment is required for cosmetic reasons. - Benefits are limited to Beneficiaries younger than 18 years. - Only one Beneficiary per family may commence orthodontic treatment in a calendar year, except in the case of identically aged siblings. - Orthodontic re-treatment is not covered. - Orthognatic surgery (jaw correction surgery) and the associated hospital admission, is not covered. - Benefits for orthodontic treatment are granted as a percentage of MST per procedure code. The applicable procedure is paid as follows: - A deposit when the treatment starts and the balance of the tariff over the estimated treatment period. - The Member is responsible for paying the outstanding balance in respect of the deposit as well as the monthly amounts for the duration of the treatment period. - Relevant X-rays, treatment plans and clinical photographs must be faxed to DENIS on 0866 770 336, or e-mailed to ortho@denis.co.za.

094

KEYHEALTH MEMBER GUIDE 2012

Implants Benefit for implant treatment is only available on the Platinum option. Hospital benefits are not available for dental implants. Sinus lifts and bone augmentation procedures for implants are not covered. Relevant X-rays and treatment plans must be faxed to DENIS on 0866 770 336, or e-mailed to ortho@denis.co.za.

Periodontics - Periodontal benefit is only available to Beneficiaries who are registered on the Perio Programme. - Beneficiaries must register on the Perio Programme by submitting the CPITN score (supplied by the Dental Practitioner) together with the periodontal treatment plan to perio@denis.co.za, or alternatively faxing it to 0866 770 336. - Further clinical records may be requested to process the application. - Surgical periodontics is a Scheme exclusion.

8.3| HOSPITALISATION BENEFITS


Pre-authorisation for dental treatment in a hospital must be obtained by contacting the DENIS Call Centre on 0860 104 926, at least 48 hours prior to the planned treatment. Hospitalisation for dentistry is not automatically covered and is subject to DENIS authorisation, where the following protocols apply: - General anaesthetic benefits are available on the Platinum and Gold options for very young Child Dependants who require extensive dental treatment (multiple extractions and fillings). - Multiple visits to theatre are not covered.

KEYHEALTH MEMBER GUIDE 2012

095

NOTES:

09 | OPTICAL BENEFITS

098

KEYHEALTH MEMBER GUIDE 2012

09| OPTICAL BENEFITS


Opticlear manages optical benefits of Beneficiaries on behalf of the Scheme. The Scheme pays benefits for optical treatment up to 100% MST and in accordance with Scheme Rules and optical protocols. Lenses and contact lenses must be prescribed by a registered Optometrist or Ophthalmologist, and must be aimed at improving the patients visual acuity. Opticlear important contact details: Call Centre telephone number: Call Centre fax number: 0861 678 427 0861 100 397

(See the Benefit Structure in this Member Guide for the Optical Benefits.)

KEYHEALTH MEMBER GUIDE 2012

099

NOTES:

10 | EMERGENCY TRANSPORT

0102 KEYHEALTH MEMBER GUIDE 2012

10| EMERGENCY TRANSPORT


AMBULANCE SERVICES Netcare 911 provides Beneficiaries with unlimited emergency service benefits while managing the medical care provided to patients in the pre-hospital environment, including all associated transportation costs. Emergency benefit: - Emergency response to the scene of the accident is provided by road or air ambulance via the Netcare 911 Call Centre by dialing 082 911 countrywide. - The Beneficiary involved or someone representing him/her needs to obtain authorisation for emergency transport in order for Netcare 911 to ensure that ambulance services are utilised appropriately and emergency ambulance infrastructure is available to clients who require medical transportation. - In the event of another ambulance service provider inadvertently being used, the Beneficiary or someone representing him/her must contact Netcare 911 within 24 hours to obtain authorisation for the ambulance transfer. Transfers: - Authorisation for ambulance transfers must be obtained from Netcare 911 on 082 911. - Medically justified transfers to special care centers or inter-hospital transfers take place according to Netcare 911 protocols. The Scheme provides Netcare 911 with clinical and Rule-based guidelines with regard to these transfers. Additional services provided by Netcare 911: - Taking care of uninjured minors; - Repatriation; - Transfers to Rape Crisis Centers of Excellence; - Information regarding Netcare Travel Clinics, contact 0800 223 434 (Health on Line); - Telephonic medical advice and information. Reasons for non-payment of emergency transport related claims: - No authorisation for emergency transport was requested and obtained from Netcare 911 within 24 hours of incident; - Not medically justified in terms of Netcare 911 protocols; - In case of a transfer, no authorisation was obtained from Netcare 911; and/or - The relevant claim was received more than four (4) months after the service date (date on which the patient was transported).

KEYHEALTH MEMBER GUIDE 2012 0103

NOTES:

11 | CO-PAYMENTS

0106 KEYHEALTH MEMBER GUIDE 2012

11.1|CO-PAYMENTS ON SPECIFIC SURGICAL PROCEDURES


PROCEDURE
Varicose vein surgery Umbilical hernia repair Facet joint injections Functional nasal surgery Hysterectomy Rhizotomy Reflux surgery Back surgery (including spinal fusion) Joint replacements

(PER ADMISSION / SILVER, EQUILIBRIUM AND ESSENCE OPTIONS):


CO-PAYMENT
R1 000 R1 000 R1 000 R2 000 R2 500 R2 500 R5 000 R5 000 R5 000

11.2|CO-PAYMENTS ON SPECIFIC ENDOSCOPIC PROCEDURES


(IN-HOSPITAL / PER SCOPE / ALL OPTIONS):
PROCEDURE
Arthroscopy Laparoscopy (diagnostic) Hysteroscopy Colonoscopy Cystoscopy Gastroscopy Sigmoidoscopy Pre-authorisation compulsory. No co-payments on out-of-hospital scopes.

CO-PAYMENT
R2 500 R2 500 R2 000 R1 500 R1 500 R1 500 R1 500

KEYHEALTH MEMBER GUIDE 2012 0107

11.3|LIST OF CO-PAYMENTS PER OPTION:


BENEFIT
In-hospital In- or out-ofhospital In-hospital Internal/external prosthesis MRI and CT scans Endoscopic procedures Category A (CDL) CO-PAYMENT EXPLANATORY NOTES Upon exceeding the R55 000 pfpa limit Payable directly to the service provider involved Payable directly to the hospital involved When using a non-DSP pharmacy Payable directly to the service provider involved Payable directly to the service provider involved When not using a DSP pharmacy Payable directly to the service provider involved Payable directly to the service provider involved All day-to-day services within threshold Payable directly to the service provider involved

PLATINUM OPTION
20% R1 000 per scan See 11.2 above 10% 10% on nonPMB conditions 10%

Chronic medicine

Chronic medicine

Category B (other)

Chronic medicine

Category B (other)

Out-of-hospital

Pathology

20%

Out-of-hospital

Threshold

10%

Dentistry

Refer to the benefit structure summary

GOLD OPTION
In- or out-ofhospital In-hospital MRI and CT scans Endoscopic procedures Category A (CDL) R1 000 per scan See 11.2 above 15% Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved Payable directly to the service provider involved

Chronic medicine

Out-of-hospital Dentistry

Pathology

40%

Refer to the benefit structure summary

0108 KEYHEALTH MEMBER GUIDE 2012

BENEFIT
In-hospital In- or out-ofhospital In-hospital Specific procedures MRI and CT scans Endoscopic procedures Category A (CDL)

CO-PAYMENT

EXPLANATORY NOTES Payable directly to the hospital involved Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved Payable directly to the service provider involved

SILVER OPTION
See 11.1 above R1 000 per scan See 11.2 above 30%

Chronic medicine

Out-of-hospital Dentistry

Pathology

40%

Refer to the benefit structure summary

EQUILIBRIUM OPTION
In-hospital In- or out-ofhospital In-hospital Specific procedures MRI and CT scans Endoscopic procedures Category A (CDL) See 11.1 above R1 000 per scan See 11.2 above 30% Payable directly to the hospital involved Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved

Chronic medicine Dentistry

Refer to the benefit structure summary

ESSENCE OPTION
In-hospital In- or out-ofhospital In-hospital Specific procedures MRI and CT scans Endoscopic procedures Category A (CDL) See 11.1 above R1 000 per scan See 11.2 above 30% Payable directly to the hospital involved Payable directly to the service provider involved Payable directly to the hospital involved When not using a DSP pharmacy Payable directly to the service provider involved

Chronic medicine Dentistry

Refer to the benefit structure summary

KEYHEALTH MEMBER GUIDE 2012 0109

NOTES:

12 | CLAIMS

0112 KEYHEALTH MEMBER GUIDE 2012

12.1|CLAIMS PROCEDURES
The Scheme strives to make the claims procedure for Members as user-friendly as possible. In most cases, claims are submitted by service providers, i.e. Doctors, Dentists, Physiotherapists, and Pharmacists etc., on behalf of the Beneficiaries involved. The Scheme must emphasise, however, that Members should check all claim entries on every claims statement to ensure that the services charged were indeed rendered to them: - By doing this, Members will be able to notice any inaccurate claims against their benefits. - If there appears to be a problem on any claims statement, the Member must first contact the service provider involved and enquire about the claim(s) submitted. - If services were indeed not rendered, contact the Scheme and point out the discrepancies, as the Scheme would like to ensure that the Member only pays for services rendered.

Claims for cash payments


If Members pay cash for services covered by their benefits, they can claim back directly from the Scheme: - When paying cash, please remember to request a detailed account and a receipt as proof of payment. - Clearly mark the account submitted as Refund Member. Before submitting these claims, ensure that all accounts show the following details: - Member information: > The Principal Members initials and surname as it appear on the latest membership card; > The membership number; > The name of the Scheme and the benefit option; > The patients first name(s) and surname, and dependant code as indicated on the latest membership card. Please note: Ensure that the Scheme has the correct banking details for claims reimbursement. - Provider information: > The name and practice number of the service provider (Doctor, hospital, pharmacy, etc.); > The referring Doctor and practice number, in the case of a Specialists account.

KEYHEALTH MEMBER GUIDE 2012 0113

- Services rendered: > The date of the service or treatment; > The nature and cost of each service or treatment item and the tariff code(s) [ICD-10 code(s)] involved; > The duration of an operation (where applicable); > The name, quantity, price and NAPPI code of each item of medication (where applicable). Take note: If the claim submitted does not contain all the necessary information, it will delay the process, thus delaying benefit payment. The Principal Member must sign and mail the original account and receipt to: KeyHealth Medical Scheme P Box 14145 .O. Lyttelton 0140 Scheme reimbursement to Members: - Any money owed to Members will be paid into their bank account, provided that the Scheme has their correct banking details; - Payments to Members are made monthly, provided that the amount payable is in excess of R50,00. If the amount payable is less than R50,00, payment will only be made once the accumulated amount reaches R50,00. Submission of claims: - Claims received by the Scheme within four (4) months of the date of treatment or service, will be processed according to Scheme Rules; - If an account is not submitted within the above mentioned period, no benefits will be payable. Please note: A receipt without the appropriate detailed account will not be considered for payment. Claims information supplied: - Processed claims will be indicated on the claims statement as follows: > Amounts paid by the Scheme, and to whom payment was made; > Refunds to Members by the Scheme (if any); > Payments owed to the Scheme by Members or any service provider (Doctor, hospital etc.); > The balance of Member benefits for the current benefit year.

0114 KEYHEALTH MEMBER GUIDE 2012

- Members will also receive e-mail confirmation of claims processed (if the Scheme has the e-mail address on its database).

Claims submitted to the Scheme by the service provider:


Most providers of medical services and pharmacies have an electronic link to the Scheme, meaning that claims are submitted directly to the Scheme on behalf of Members. Members are entitled to receive copies of these accounts from the service provider(s) involved.

Outstanding claims on resignation or death:


Claims submitted within four (4) months will be considered for payment, provided the service date was prior to the date of resignation or death of the Beneficiary involved.

Most common reasons for partial payment of claims:


There may be a difference between the actual claim for the services rendered and the benefit paid by the Scheme; in other words, where the claim amount exceeds MST; When annual benefits are exhausted; Where co-payments are applicable.

Non-payment of claims:
Services, material or medicine items are excluded from the Schemes benefits; Service provider is not registered with an acknowledged professional institution; Allocated benefits for a specific benefit year have been exhausted; Invalid tariff code, diagnostic or NAPPI code(s) reflected on the claim; Member or Dependant not registered on the Scheme; Benefits suspended at the time of treatment/service delivery; No authorisation was obtained for a specific service item; Claims have a service date older than four (4) months.

KEYHEALTH MEMBER GUIDE 2012 0115

12.2 | MOTOR VEHICLE ACCIDENT (MVA)


In case of an MVA, and where a Member and/or Dependant(s) sustained injuries requiring medical attention, take note of the following: - Contact the Client Service Centre on 0860 671 050 to inform the Scheme as soon as possible after the accident. - If a claim is instituted with the Road Accident Fund (RAF) and/or any other third party, the Member concerned provides the Scheme with a written undertaking signed by the Member and/or the Members attorney involved. - The above mentioned document confirms the Members undertaking to reimburse the Scheme for costs defrayed relating to relevant medical expenses, in the event of the claim being favourably considered by the RAF and/or any third party. - On receipt of the undertaking, the Scheme will consider all relevant medical accounts for processing in accordance with the Scheme Rules. - If a claim is not instituted at the RAF, all medical claims relating to the MVA will be considered for processing against the Members benefits and limits, and the prevailing Scheme Rules.

12.3 | INJURY ON DUTY (IOD)


No medical claims of Beneficiaries arising from an IOD are covered by the Scheme. All IOD claims must be submitted to the Compensation Commissioner by the employer of the Beneficiary involved, without delay. Should it happen that claims applicable to an IOD are inadvertently paid by the Scheme; the Scheme must be informed immediately. The claims will be reprocessed and the applicable amounts will be recovered from the relevant service provider(s).

12.4 | CLAIMS STATEMENT


Members will be informed on a statement of all claims, activities and benefits utilised. Members are friendly, yet urgently requested to carefully read every statement and to keep records for future reference, should any queries arise.

0116 KEYHEALTH MEMBER GUIDE 2012

12.5|TRAVELLING ABROAD
To qualify for the reimbursement of out-of-hospital medical claim expenses incurred by a Beneficiary during the first ninety (90) days of travelling abroad, the Principal Member involved must inform the Scheme of the following in writing at least one (1) month in advance: - The full name and surname, and the dependant code of the Beneficiary(ies) who will be undertaking the planned foreign visit; - The name(s) of the country/countries to be visited; - The starting and end date of the visit. Please note: The Scheme may exercise sole discretion if informed within a shorter period of time. Upon receipt of the above mentioned information, the Scheme will issue a letter to the Principal Member involved, confirming the terms and conditions of medical cover during the intended foreign visit. During the foreign visit, the travelling Beneficiary(ies) will be liable for all expenses regarding out-ofhospital medical treatment. On return, or within four (4) months after the date of service, the Member applies to the Scheme for the reimbursement of the above mentioned claims by submitting the relevant account(s), together with the proof of payment. Reimbursement will be subject to the Members available day-to-day benefits and will be calculated using the foreign exchange rate applicable on the date of service and the appropriate South African tariffs for services rendered. Any elective/planned procedure performed outside of South Africa, will not be covered.

In-hospital medical treatment:


The Scheme shall not be liable for any expenses incurred by a Beneficiary with regard to in-hospital medical treatment during the course of a foreign visit. Members are urged to timely make their own arrangements in respect of obtaining additional travel insurance to cover in-hospital expenses incurred during foreign visits.

KEYHEALTH MEMBER GUIDE 2012 0117

NOTES:

13 | MEDICAL SAVINGS ACCOUNT (MSA)

0120 KEYHEALTH MEMBER GUIDE 2012

13| MEDICAL SAVINGS ACCOUNT (MSA)


Please note: In terms of legislation, a scheme member is not allowed to make any additional voluntary deposit into his/her medical savings account.

The Gold and Equilibrium options each provides for a medical savings account:
Note: See the Gold and Equilibrium options (chapter 3) for monthly and total medical savings amounts. - Medical savings are allocated in advance for the full benefit year (i.e. annual medical savings); any medical savings not being utilised during a specific benefit year will be carried over to the following benefit year. - The Members annual medical savings balance will be utilised first for all day-to-day medical expenses. When annual savings are exhausted, day-to-day expenses will then be covered from the applicable benefits. - After exhausting the day-to-day benefits, the available savings balance (i.e. carried forward savings) from previous years will be utilised.

Provision has been made by the Scheme for debt redemption on the medical savings account. This means that any money due to the Member will, after debt redemption, be refunded in the following instances:
Change of option: Should the selected new option not make provision for a savings account. - Resignation (1): Should a Member resign from the Scheme during the year and the Members new medical scheme does not have a savings option, the savings amount will be paid out to the Member. Should a Member resign from the Scheme during the year and the Members new medical scheme does have a savings option, the savings amount will be paid out to the new medical scheme.

- Resignation (2):

Please note: Allow up to five (5) months for the medical savings account credit balance to be refunded.

KEYHEALTH MEMBER GUIDE 2012 0121

In the event of the savings amount allocated to the Member being exceeded/exhausted before 31 December, the Member will be liable to refund the amount due to the Scheme in the following instances:
- Change in KeyHealth option should the new option, selected by the Member, not make provision for a savings account; - In the event of the Member resigning from the Scheme.

The following medical expenses can also be paid from a Members medical savings account:
Co-payments; Payments of amounts where the maximum benefits were exceeded; Payments for services excluded from benefits; Payment for services rendered during waiting periods; Payment for services rendered in respect of underwriting exclusions.

A Members savings account may not be utilised to pay for any expenses regarding PMB and CDL conditions.

14 | LIST OF EXCLUSIONS

0124 KEYHEALTH MEMBER GUIDE 2012

14| LIST OF EXCLUSIONS


With the exception of the Prescribed Minimum Benefits (PMBs), and unless specific provision has been made in the Scheme Rules for benefits, no benefits will be payable in respect of the following;
Costs incurred for treatment arising out of an injury sustained by a Beneficiary for which any third party is liable. The Beneficiary is, however, entitled to such benefits as would have applied. Provided that on receipt of payment in respect of resultant third party claims, the Principal Member will reimburse the Scheme any payments made by the Scheme in respect of these claims. Services exceeding the maximum benefits to which the Beneficiary is entitled to, as contained in the Scheme Rules. The cost of services rendered by the following: - Persons not registered with an acknowledged professional institution which was established or registered in accordance with relevant legislation; - Any institution, nursing institution or similar institution, except a State Hospital, which are not registered in accordance with relevant legislation; - Costs incurred for treatment arising out of an injury or disablement resulting from war, invasion or civil war, except for PMBs; - Any expenses incurred by a Beneficiary who has been duly certified as mentally unsound; - Injuries resulting from occupational sport, speed contests and speed trials, except for PMBs; - Attempted suicide, willfully self-inflicted injuries or sickness conditions/costs incurred in respect of treatment associated with drug abuse or overdosing, including Alkogen treatment, except for PMBs; - Accommodation or lodging fees in convalescent or old age homes, institutions for the physically or the mentally handicapped or similar institutions; - Accommodation and treatment in spas and resorts for health, slimming, chiropractic, homeopathic or similar purposes; - Accommodation in a private room of a hospital, unless prescribed by a Medical Practitioner and approved by the Scheme; - The cost of holidays for recuperative purposes, whether deemed medically necessary or not; - Medical examinations for insurance, school camp, visa, employment or similar purposes; - Travelling costs incurred by Beneficiaries; - Medical examinations, consultations, treatment, operations and procedures relating to:

KEYHEALTH MEMBER GUIDE 2012 0125

> Acupuncture; > Bio-kinetics; > Bio-stress assessments; > Colonic irrigation; > Cosmetic purposes; > DNA testing; > EBCT Computed Tomography Coronary and Heart; > Gastroplasty; > IQ tests and learning problems; > Obesity; > Reversal of sterilization; > Reversal of vasectomy; > Sclerotherapy of varicose veins. - In respect of the PMB code 902M, Infertility, the following services are excluded: > Assisted Reproductive Technology (ART) techniques, including In Vitro Fertilisation (IVF); > Gamete Intra-Fallopian Tube Transfer (GIFT); > Intra-cytoplasmic Sperm Injection (ICSI); > Zygote Intra-Fallopian Tube Transfer (ZIFT). - Charges for the following: > Ante- and post-natal exercise classes; > Appointments not kept; > Breast-feeding instructions; > Emergency unit fees, except for trauma/emergencies/PMBs and consultations leading to hospitalisation; > Mother-craft; > Telephonic consultations with Medical Practitioners; > Water-births. - Purchase or hire of the following equipment: > > > > > APS therapy machines or similar devices; Bedpans; Blood-pressure monitors; Commodes; Cushions;

0126 KEYHEALTH MEMBER GUIDE 2012

> > > > > > > > > >

Health shoes, e.g. Green Cross; Humidifiers; Kidney belts; Mattresses, including Numbis mattresses; Medic Alert bands; Peak flow meters; Sheepskin; Special beds or chairs; Waterbeds; Waterproof sheets.

- The purchase of: > Growth hormones; > Household remedies or preparations of the type advertised to the public; > Medicines that are not prescribed on a written prescription of a person authorised by relevant legislation; > Mouth protectors, gold inlays, devices and materials such as floss, toothbrushes and toothpaste; > Other supplements; > Slimming preparations, appetite suppressants, food supplements and patent foods, including baby foods; > Soaps, shampoos and other topical applications, medicated or otherwise; > Sun-screening and tanning agents; > Synvisc injection; > Vitamins without a Nappi code. - General optical benefit exclusions: > > > > > > > > Contact lense solutions; Lenses with a tint exceeding 35%; Scripts less than 0.50 dioptre; Spectacle cases; Spectacle repairs; Sunglasses; The fee associated with the fitting and adjustment of contact lenses; Charges for repairs of medical appliances (for the maintenance of hearing aids, see the Benefit Structure).

KEYHEALTH MEMBER GUIDE 2012 0127

General dental benefit exclusions with due regard to the PMBs:


Apisectomies in the hospital; Bleaching, front tooth laminate veneers and composite veneers; Bone and other tissue regeneration procedures; Bone augmentations; Caries susceptibility and microbiological tests; Conservative dental treatment (fillings, extractions and root canal therapy) in the hospital for adults; Cost of bone regeneration material; Cost of gold, precious metal, semi-precious metal and platinum foil; Cost of invisible retainer material; Cost of Mineral Trioxide; Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments; Crowns on third molars (wisdom teeth); Dental bleaching and porcelain veneers; Dentectomies in the hospital; Diagnostic dentures; Dolder bars and associated abutments on implants (including the laboratory cost); Electrognathographic recordings and other such electronic analyses; Endodontic procedures on third molars, unless clinically motivated; Fillings to restore teeth damage due to toothbrush abrasion; Fissure sealants on patients older than 16 years; Fixed prosthodontics (crowns) used to repair teeth damaged due to bruxism (tooth grinding); toothbrush abrasion; erosion or fluorosis; Fixed prosthodontics (crowns) used to restore teeth for cosmetic reasons; Fixed prosthodontics (crowns) where a reasonable attempt has not been made to restore/replace the tooth conservatively; Fixed prosthodontics (crowns) where the mouth is periodontal compromised; Fixed prosthodontics (crowns) where the tooth has been recently restored to function; Fixed prosthodontics used to repair acclusal wear; Frenectomies in the hospital; Gingivectomy; High-impact acrylic; Hospitalisation for any dental treatment other than the removal of impacted teeth on the Essence and Silver options; Hospitalisation for surgical tooth exposure for orthodontic reasons; Laboratory cost associated with mouth guards (including material cost); Laboratory cost of provisional and emergency crowns; Laboratory costs, where the associated dental treatment is not covered; Laboratory delivery fees;

0128 KEYHEALTH MEMBER GUIDE 2012

Laboratory fabricated crowns on primary teeth; Lingual orthodontics; Full metal base to dentures; Metal, porcelain or resin inlays, except where such inlays form part of a bridge; Nutritional and tobacco counseling; Oral hygiene instructions; Orthodontic re-treatment; Orthognatic (jaw correction) surgery and the related hospital cost; Ozone therapy; Perio Chip; Periodontal flap surgery and tissue grafting; Polishing of restorations; Pontics on second molars; Porcelain or resin inlays, except where the inlay forms part of a bridge; Professional oral hygiene procedures in the hospital (scale, polishing and fluoride treatment); Professionally applied topical fluoride in adults; Provisional crowns; Pulp capping (direct and indirect); Resin bonding for restorations charged as a separate procedure; Root canal treatment on third molars (wisdom teeth) and primary teeth; Sinus lifts; Snoring appliances; Soft base to new dentures; Surgery and hospitalisation associated with dental implants; Three-quarter crowns (cast metal and porcelain).

KEYHEALTH MEMBER GUIDE 2012 0129

NOTES:

15 | HEALTH BOOSTER

0132 KEYHEALTH MEMBER GUIDE 2012

15| HEALTH BOOSTER


A programme available on all options to provide Beneficiaries with certain additional benefits for preventative care:
Only the benefits stated in the Benefit Structure under Health Booster, and applicable to that particular benefit option, will be paid by the Scheme; up to a maximum rand value which is determined according to specific tariff codes.

Pre-authorisation:
To qualify for any Health Booster benefit, Members must: - Contact the Client Service Centre on 0860 671 050 and obtain pre-authorisation. (Failing to do this will result in the service costs being deducted from day-to-day benefits.); - Verify the tariff code or maximum rand value with the Call Centre Consultant; - Inform the relevant service provider accordingly.

Screening tests:
One of the benefits available on the Health Booster programme is the Health Assessment. This assessment comprises the following screening tests: Body Mass Index (BMI); Blood sugar (finger prick test); Total Cholesterol (finger prick test); Blood pressure (systolic and diastolic).

Principal Members and their Adult Dependants are entitled to one Health Assessment per calendar year and must have the screening tests done at a KeyHealth DSP pharmacy. A Health Assessment (HA) form can be obtained at any KeyHealth DSP pharmacy or downloaded from KeyHealths website at www.keyhealthmedical.co.za. Results can be submitted by either the Member or the service provider, and must be faxed to 0860 111 390, for attention: Health Assessment. Results of these screening tests may require follow-up tests. For this purpose, additional blood sugar and cholesterol tests are available on the Health Booster programme. Please note: No authorisation is required for these screening tests.

KEYHEALTH MEMBER GUIDE 2012 0133

TYPE PREVENTIVE CARE*


Baby immunisation Flu vaccination Tetanus diphtheria injection Pneumococcal vaccination**

WHO & HOW OFTEN?


Child Dependants aged 6 as required by the Department of Health. Beneficiaries aged 18 once per year. Beneficiaries aged 60 once per year. High risk Beneficiaries once per year. All Beneficiaries as and when required. Beneficiaries aged 60, and high risk as and when required. Female Beneficiaries aged 15 once per year. Female Beneficiaries aged 15 once per year. Female Beneficiaries aged 40 once every 2 years. Beneficiaries aged 30 and 59 once every 3 years. Beneficiaries aged >59 and 69 once every 2 years. Beneficiaries aged >69 once per year. Male Beneficiaries aged 40 and 49 once every 5 years. Male Beneficiaries aged >49 and 59 once every 3 years. Male Beneficiaries aged >59 and 69 once every 2 years. Male Beneficiaries aged >69 once per year. Beneficiaries aged 25 once per year. Beneficiaries all ages once per year. Beneficiaries aged 15 once every 5 years.

EARLY DETECTION TESTS*


Pap smear (Pathologist) Pap smear (consultation; GP or Gynaecologist) Mammogram General physical examination

Prostate specific antigen (Pathologist) Cholesterol test (Pathologist) Blood sugar test (Pathologist) HIV/AIDS test (Pathologist) Health Assessment (HA) Body mass index, Blood pressure measurement, Cholesterol test (finger prick), Blood sugar test (finger prick)

Adult Beneficiaries once per year.

MATERNITY*
Antenatal visits (GP or Gynaecologist) & urine test (dipstick) Scans (one before the 24th week and one thereafter) Paediatrician visits Female Beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. Twelve (12) visits. Female Beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. Two (2) pregnancy scans. Baby registered on Scheme. Two (2) visits in babys 1st year.

*Pre-authorisation essential to access benefits **Only available on Platinum, Gold and Silver options

16 | FRAUD / UNETHICAL CONDUCT

0136 KEYHEALTH MEMBER GUIDE 2012

16| FRAUD / UNETHICAL CONDUCT


The cost of medical fraud / unethical medical conduct in South Africa is estimated at billions of rands every year. This constitutes a huge financial loss, not only to medical schemes, but indirectly to every scheme member in the country. Fraud / unethical conduct is mainly committed for economic, egocentric, ideological and psychological reasons, of which the economic motive is the most common. Detection of fraud / unethical conduct is, for the most part, time consuming and costly. In view of this, KeyHealth depends largely upon its Beneficiaries and suppliers to report any form of fraud / unethical conduct; whether reporting occurs openly or anonymously. In this regard, KeyHealth makes use of the services available from its Administrator to provide a safe channel where anonymity is guaranteed to those who wish to report on (suspected) malpractices. All reported cases are then handed over to the Schemes Internal Audit department in order to conduct the necessary investigations. Report any (suspected) fraud / unethical conduct at 0860 110 820 (Monday to Friday, 07:30 until 16:00, public holidays excluded), or via e-mail at fraud@keyhealthmedical.co.za.

KEYHEALTH MEMBER GUIDE 2012 0137

NOTES:

17 | ELECTRONIC COMMUNICATION

0140 KEYHEALTH MEMBER GUIDE 2012

17.1| VIA THE INTERNET


www.keyhealthmedical.co.za
KeyHealths website on the worldwide web is an informative, interactive gathering place for Members, Service Providers, Brokers and the Scheme.

Easy steps to register as an internet user:


Access the KeyHealth website on www.keyhealthmedical.co.za. In the Online Services field, click on Register. Click on Register now under the Member registration heading. Please choose the relevant registering option: - Option 1: Register online - Option 2: Call the contact centre - Option 3: Activation request

When choosing Option 1: - Enter the relevant KeyHealth member number and click on Validate. - Complete the following fields: surname, first name, ID number and e-mail address. Take note: If any of the completed fields do not correspond with the information on the Schemes system, registration will be unsuccessful. - The password is sent to the Member via e-mail/sms. The following message appears on the screen: Thank you for registering for web access. Your new password has been sent via e-mail/sms once you have received it, you may log in immediately. Click on Log in. The user is requested to change his/her password. Do this by entering the relevant member number and the old and new password. The following message appears on the screen: Thank you - your password was successfully changed. Click on continue. Log in by using the new password.

KEYHEALTH MEMBER GUIDE 2012 0141

Forgotten Password:
In the Online Services field, click on Forgot Password. In the Login field, type in the username. Select Member. Click on Submit. The new password is received via e-mail/sms. The user is requested to change his/her password. Do this by entering the member number and the old and new password. The following message appears on the screen: Thank you - your password was successfully changed. Click on continue. The Member can now log in using the new password.

Online enquiries:
Members can view their claims history and personal information by completing their username and password in the Online Services field. The Summary information page is displayed once logged in. The following information can be viewed: - Summary a summary of the members personal details as well as a list of the last 5 claims, 6 statements and 6 contributions. - Details this page contains all of the Members personal, contact, Scheme, address, employment and banking details. - Claims all available claims submitted. - Benefits this category includes a summary of the Members maximum, used and available benefits. - Statements - all available claims statements. - Contributions a view of the Members contribution history. - Waiting periods a list of the waiting periods applicable to dependants. - Correspondence the previous correspondence between the Member and the Scheme. - Enquiry a summary of the Members enquiries. - Providers a facility where the Member can search for a provider. - Cases - the Members authorisation history. - Health Info detailed information on chronic conditions, lifestyle conditions and clinical reference. - GRP and medicine search to search for product information by using the product name.

0142 KEYHEALTH MEMBER GUIDE 2012

17.2| VIA E-MAIL (WEBMAIL)


Webmail is an e-mail based interface enabling Members to access their Scheme information, without having to phone the Client Service Centre. The Member can activate a webmail by e-mailing the Scheme at webmail@keyhealthmedical.co.za; no details are required in the subject field or the body of the mail. The e-mail address of the Member will be authenticated against the e-mail address loaded onto the system. If the Members e-mail address is not registered onto the system or if there is more than one Member using the same e-mail address, the user will receive a response, informing him/her that the Scheme is unable to authenticate this e-mail address and is therefore unable to generate the webmail. If the Members e-mail address is authenticated, the system will e-mail a complete package of information. This package includes: - Membership details; - Case History; - Claims History - Benefits; - Contributions.

17.3| VIA SMS


Members have access to useful information 24 hours a day by sending an SMS to 32899. The different options are as follows: - Send an SMS with the letter B as the message - receive an SMS with the Members current benefits available. - Send an SMS with the letter C as the message - receive an e-mail with the Members latest claims. - Send an SMS with the letter D as the message - receive an SMS with the Members current membership details. - Send an SMS with the letters IC and the relevant ICD-10 code as the message - receive an SMS with the ICD-10 code description details. The Member should receive a reply within minutes, provided his/her current mobile number is available on the Schemes administrative system. Contact the Client Service Centre on 0860 671 050 to update personal details (Mondays to Fridays between 07:30 and 18:00, and Saturdays between 08:00 and 12:00, public holidays excluded).

KEYHEALTH MEMBER GUIDE 2012 0143

NOTES:

18 | IMPORTANT CONTACT INFORMATION

0146 KEYHEALTH MEMBER GUIDE 2012

18| IMPORTANT CONTACT INFORMATION


Client Service Centre e-mail Netcare 911 Hospital pre-authorisation e-mail Oncology management programme e-mail DENIS (dental) pre-authorisation e-mail 0860 671 050 info@keyhealthmedical.co.za 082 911 0860 671 060 Preauth@keyhealthmedical.co.za 0860 671 060 oncology@keyhealthmedical.co.za 0860 104 926 keyhealthenq@denis.co.za Fax : 0866 770 336 Fax : 012 679 4469 Fax: 0860 111 390

Fax: 012 679 4471

DENIS ( dental) claims enquiries / Submissions e-mail claims@denis.co.za LifeSense disease management Crisis line ( Netcare 911) Chronic medication registration (to be used by providers) Optical management 0860 50 60 80

082 911

0800 132 345

0861 678 427 Fax : 0861 100 397

Fraud/Ethics line e-mail New Business e-mail

0860 110 820 fraud@keyhealthmedical.co.za 012 667 5100 newbusiness@keyhealthmedical.co.za

Fax: 0866 050 656

KEYHEALTH MEMBER GUIDE 2012 0147

Membership e-mail Broker queries (Client Service Centre) e-mail Website

0860 671 050 membership@keyhealthmedical.co.za billing@keyhealthmedical.co.za 0860 671 050 brokersupport@keyhealthmedical.co.za www.keyhealthmedical.co.za KeyHealth Medical Scheme P Box 14145 .O. Lyttelton 0140

Fax : 0860 111 390

Postal address:

KeyHealth Client Service Centre business hours:


The Client Service Centre is available Mondays to Fridays between 07:30 and 18:00, and Saturdays between 08:00 and 12:00, public holidays excluded.

WALK-IN OFFICES: Centurion Block D


Corporate Park 66 Cnr. Lenchen Avenue and Von Willich Street Die Hoewes Centurion

Durban

2nd floor Momentum House Cnr. Florence Nzama Street (previously Prince Alfred Street) and Bram Fisher Road (previously Ordnance Road) Old Fort Durban

You might also like